The Pitfalls of Febrile Jaundice. A Case Report.

Jaundice in sepsis is usually caused by cholestasis, and its onset can precede other manifestations of the infection. Inflammation-induced cholestasis is a common complication in patients with an extrahepatic infection or those with inflammatory processes. We describe the case of a 47 years old female who presented with low back pain and paravertebral muscular contracture. She subsequently developed a cholestatic syndrome with clinical manifestations such as jaundice, followed by fever and sepsis with multiple organ dysfunction. Initially labeled as biliary sepsis, the diagnosis was crucially reoriented as the blood cultures were positive for Streptococcus pyogenes and the magnetic resonance imaging (MRI) findings suggested spondylodiscitis as well as a paravertebral abscess.

Tuberculous Meningitis in Children and Adults: A 10-Year Retrospective Comparative Analysis.

BACKGROUND: Tuberculous meningitis (TBM) is the most lethal form of Mycobacterium tuberculosis infection, which has a high rate of neurological complications and sequelae. OBJECTIVES: Our study offers a real-world infectious disease clinic perspective, being thus representative for the clinical environment of developing countries. METHODS: We performed a retrospective analysis of the 127 adult and 77 pediatric cases diagnosed with TBM in the Infectious Disease Hospital of the School of Medicine of Iasi, Romania between 2004-2013. RESULTS: Definite diagnosis of TBM was established in 31% of children but in only 20% of adults (p = 0.043). A contact with an individual with pulmonary tuberculosis was documented in 30% of children vs. 13% of adults (p = 0.0007). Coma occurred in 19% of patients (similar in children and adults); other consciousness abnormalities were seen in 27% of children and in 72% of adults (p = 0.000001). Cranial nerve palsies occurred prior to therapy in 9% of cases (12% vs 7% of children and adults, respectively, p>0.05), and developed 2-7 days after treatment initiation in 10% (12 vs 9%). CSF cultures were positive for M. tuberculosis in 24% of patients (31% vs. 20%, p>0.05). Overall mortality was 7.35%, similar for children and adults. Yet, permanent neurological sequelae, which were seen in 23% of patients occurred significantly more frequent in children vs. adults (36% vs. 14%, respectively, p = 0.0121). In conclusion, our retrospective analysis on a significant number of cases of TBM identified striking differences between children and adults: while children were in an earlier stage at the admission, they associated a higher frequency of neurological sequelae and miliary pattern, and they were more likely to have normal CSF protein levels and positive cultures of CSF.

CHARACTERISTICS OF HEPATITIS B VIRUS COINFECTION AMONG HIV-INFECTED PREGNANT WOMEN.

UNLABELLED: The similar routes of transmission for HIV and HBV place patients with either infection at greater risk for HIV/HBV co-infection. AIM: To determine the particularities of hepatitis B virus (HBV) coinfection in pregnant women infected with human immunodeficiency virus (HIV) and its influence on pregnancy. METHODS: Retrospective study of 74 HIV-infected women monitored during pregnancy in the Iasi Regional HIV/AIDS Center (Romania) from 2010 to 2013. The subjects were divided into 2 groups according to the presence or absence of HBV coinfection. RESULTS: Most subjects belonged to age group 20-24 years (90% in the HIV group versus 75.5% in the HIV/HBV-coinfected group). HIV infection was most commonly transmitted by parenteral route (65.5% vs. 48.9%). The majority of patients were married (60% vs. 65%) and primiparous at the time of enrollment (71.1% vs. 96.6%). In the HIV/HBV-coinfected group CD4 level was lower and mean plasma viral load higher (1.92 log10 copies/mL vs. 2.31 log10 copies/ml). The proportion of cases with severe immunosuppression was similar in both groups (18.1% vs. 17.9%). HBV-HIV coinfection induced a risk of prematurity of 1.51 times, but did not increase the risk of newborns with low birth weight. CONCLUSIONS: Advanced stages of HIV disease, age group 21-30 years, low CD4 counts, and low levels of education are significant risk factors for preterm birth and low birth weight.

Characteristics of co infection with hepatitis B virus among Romanian patients infected with human immunodeficiency virus.

AIM: To determine the epidemiological and viroimmunological features and outcome of HIV/HBV-co infected patients cared in the lasi HIV/AIDS Regional Center. MATERIAL AND METHODS: This retrospective study included 252 patients diagnosed with HIV infection and associated hepatitis B virus (HBV) infection assessed at the Hospital of Infectious Diseases in the interval 2000-2013 and treated with antiretroviral drugs active against both HIV and HBV. RESULTS: The prevalence of HIV/HBV co infection was 19.9%. A slightly higher frequency of this co infection was found among males (53.2%); most patients belonged to age group 20-29 years (86.5%), mean age was 25.56 years. The predominant route of transmission was parenteral (58.5%), followed by heterosexual transmission (40.1%). The mean CD4 cell count was 246.20 cells/mm3, in over 41% of cases CD4 count ranging from 200 to 499 cells/mm3. The mean HIV plasma viral load was 142,906 copies/ml. ALT levels varied between 10-323 IU/l, average 49.90 IU/l, over 65% of subjects having pathological levels. In 21.8% of the cases, total cholesterol was very high, and in 16.8% of the patients the serum triglyceride levels were below the reference range (160 mg %). CONCLUSIONS: Our results suggest that HIV-positive patients, chronic hepatitis B infection has a high incidence, especially in younger age groups and is correlated with significant degrees of immunosuppression.

Bacterial meningitis during sepsis in diabetic patient.

UNLABELLED: The aim of the study was to evaluate the etiology, clinical features and outcome in diabetic patients with bacterial meningitis, as a nervous system determination during invasive infections. MATERIAL AND METHODS: In a retrospective study, conducted over a period of three years, we have analyzed clinical and etiological aspects of 445 patients over 18 years old, diagnosed with sepsis of known (positive cultures from normally sterile sites) or suspected etiology (positive cultures from pus), 95 of them being included in the diabetic group. RESULTS: Bacterial meningitis was diagnosed in 16 of 95 diabetic patients (16.8%) and 43 of 350 (12.3%) non-diabetic patients (chi2 = 0.98; GL = 1; p = 0.322). Among the multiple co morbidities associated in diabetic patients, as suggested by a higher Charlson score (5.44 vs. 3.25) (p = 0.001), the most common underlying condition was chronic liver disease (31.3% vs. 25.6%) (p = 0.916). The isolation of the microorganism concurrently from cerebro-spinal fluid and other sites (blood cultures and pus) was more frequently encountered in diabetics. The clinical picture was dominated by altered consciousness (68.8% vs. 23.3%) (p = 0.003), while fever was less present (37.5% vs. 88.4%) (p = 0.0003). The most frequently involved microorganism in the etiology of meningitis was S. aureus (31.3 vs. 23.3%) (p = 0.771) and Gram negative bacilli: E. coli (12.5% vs. 4.7%) (p = 0.629) and Klebsiella spp. (12.5% vs. 9.3%) (p = 0.902). CONCLUSIONS: Altered consciousness was more frequent in diabetic patients group (68.8% vs. 23.3%) (p = 0.003) where the absence of fever at admission was a more common finding than in non-diabetic septic patients with meningitis (37.5% vs. 88.4%) (p = 0.0003).

Side effects of antiviral therapy in hepatitis C virus infection-sarcoidosis - case report.

Standard therapy in chronic hepatitis C virus infection is still a combination of peginterferon alfa2a/2b and ribavirin for 48 weeks. As of side effects, there are organic side effects, such as hematologic disorders, and functional side effects, reflected in the quality of life of hepatitis C patients. Up to 30% of the patients develop specific side effects such as headache, fever, fatigue. Sarcoidosis, known as a granulomatous disease of uncertain cause, is an uncommon finding in this category of patients. This cause-effect relation is accounted for by the convergent action of peginterferon and ribavirin of stimulating type 1 T helper cells and reducing type 2 helper T cells activation. We present the case of male patient known with chronic hepatitis C who developed pulmonary sarcoidosis following antiviral therapy. The first manifestation of the disease was unexplained fever accompanied by pulmonary tract disease. The diagnosis was established by immunophenotyping in bronchial aspirate

Severe invasive listeriosis--case report.

Listeriosis is a rare food borne infection which, in the invasive form, presents as bloodstream infection, central nervous system infection, materno-fetal infection, or focal infection. Certain immunosuppressive conditions have been identified as risk factors for severe invasive disease. The invasive forms of listeriosis are associated with a high case fatality rate. We present the case of a 62-year-old male with an unremarkable medical history admitted to the Iasi Infectious Diseases Hospital for fever. headache, ataxia, and diplopia. Physical examination revealed high temperature, confusion, relative bradycardia, and signs of meningeal irritation. Laboratory test showed leukocyt osis with neutrophilia. pathological CSF findings (high WBC count with predominance of neutrophils, low glucose and high protein levels), increased liver enzymes (ALAT, ASAT, AP, gammaGT), and important renal impairment (normal levels at presentation). No abnormalities at chest x-ray, cranial CT and abdominal ultrasound. CSF and blood cultures were positive for Listeria monocytogenes. Under antibiotics (ampicillin and ciprofloxacin), the course was marked by respiratory failure requiring mechanical ventilation, coma, hypotension, tachycardia. and death 12 days after admission. The particularity of this case consists in the association of the two classical forms of invasive listeriosis, meningitis and bacteriemia, with a focal infection. acute hepatitis, and a course marked by multiple organ dysfunction syndromes and exitus in a previously apparently healthy individual.

[Etiological aspects of acute gastroenteritis--a ten-year review (1.01. 2001-31.12.2010)]. / Aspecte etiologice ale bolii diareice acute--consideratii pe cazurile internate în Clinica de Boli Infectioase Iasi în perioada 1.01. 2001-31.12.2010.

UNLABELLED: Acute gastroentritis is one of the most common diseases in humans, and continues to be a significant cause of morbidity worldwide. AIMS: To determine the bacterial pathogens associated with gastroenteritis in patients admitted to the Iasi Infectious Diseases Hospital in the last ten years. MATERIAL AND METHODS: A total of 40481 stool samples were examined using conventional methods. RESULTS: Bacteria were found in 7.36% of cases, and parasites in 9.64%; 83% of the cases were viral, micotic, or disbiotic. The bacterial etiology was dominated by Salmonella spp. (58.34%), Shigella spp. (27.08%), Yersinia enterocolitica 03 (8.53%), Campylobacter spp. (1.31%), other bacterial pathogens (EPEC, Aeromonas hydrophilla/caviae/sobria, Plesiomonas shigelloides, Bacillus cereus, Staphylococcus aureus, etc) being detected in 3.74% of the cases. Of the Salmonella species, group B (51.99%) followed by group D (45.23%) were most common. Shigella sonnei and Shigella flexneri were found in almost the same proportion (49.45% and 49.70%, respectively); Shigella boydii was isolated in only 0.85% of cases. The trend of gastroenteritis caused by bacterial pathogens is decreasing: from 355 cases in 2001 to 105 cases in 2010; three peaks have been recorded in 2002, 2005 (when Salmonella typhi was isolated in a patient), and 2008 (469, 409, and 252 cases, respectively). Bacterial gastroenteritis affected both sexes almost equally (122 males and 118 females). The most affected age groups were: 0 - 4 years, 15 - 24 years, 5 - 14 years and 25 - 39 years. CONCLUSIONS: Laboratory investigations are essential in determining the etiology of gastroenteritis. Its unpredictable incidence justifies the human and material efforts aimed at controlling the spread of potentially epidemic acute gastroenteritis.

[Aspects of the antimicrobial resistence profile in infections with Escherichia coli and Klebsiella pneumoniae in diabetic patients]. / Aspecte ale profilului de rezistenta antimicrobiana în infectii cu Escherichia coli si Klebsiella pneumoniae la pacientii diabetici.

UNLABELLED: Infections in diabetic patient remains an important cause of morbidity and mortality, triggering and maintaining a prolonged metabolic imbalance. Emergence of extented spectrum beta-lactmase (ESBL) in Escherichia coli and Klebsiella pneumoniae is a major concern, because of the atypical manner infection acts in this group of imunodepressed patients and also for the limited therapeutic solutions. For this reason we have evaluated the profile of antimicrobial resistance of these pathogens in both diabetic and non diabetic patients. MATERIAL AND METHOD: The aim of this study was to evaluate, in a retrospective case control study, the antibiotic susceptibility pattern in isolates of E. coli and Klebsiella spp. from different biological products in 49 diabetics and 150 non-diabetics admitted in The Clinical Hospital of Infectious Diseases Iasi over a period of two years. RESULTS: Most of strains of E. coli and Klebsiella spp. ESBL positive were found in uroculture. Significant differences in E. coli resistance rate between diabetics and nondiabetics were noted for amoxicillin-clavulanic acid and ciprofloxacin (31,4% vs.13,98%, p=0,04, respectively 52,9% vs. 24,46%, p=0,004). More isolates of ESBL positive K. pneumoniae were found in diabetic patients (50% vs. 24%). Ciprofloxacin resistance of K. pneumoniae was significantly higher in diabetics (75% vs 39%; p=0,05). There was no resistance in E. coli and K. pneumoniae isolates to imipenem in the diabetic group. CONCLUSIONS: The high resistance rate to quinolones and 3rd generation cefalosporins limits their use for the treatment of Escherichia coli and K. pneumoniae infections. Other alternatives for empiric therapy in community and nosocomial-acquired infections in diabetic patient remains carbapenems, aminoglycosides and colimycin.

[Risk factors for Pseudomonas aeruginosa infections, resistant to carbapenem]. / Factori de risc pentru infectiile cu Pseudomonas aeruginosa rezistent la carbapeneme.

UNLABELLED: Since their introduction in clinical practice,carbapenems have been among the most powerful antibiotics for treating serious infections cased by Gram-negative nosocomial pathogens, including Pseudomonas aeruginosa. The emergence of betalactamases with carbapenem-hydrolyzing activity is of major clinical concern. Pseudomonas aeruginosa is a leading cause of nosocomial infection. RESULTS: Risk factors for colonization with carbapenems-resistant Pseudomonas in hospital are: history of P. aeruginosa infection or colonization within the previous year, (length of hospital stay, being bedridden or in the ICU, mechanical ventilation, malignant disease, and history of chronic obstructive pulmonary disease have all been identified as independent risk factors for MDR P. aeruginosa infection. Long-term-care facilities are also reservoirs of resistant bacteria. Risk factors for colonization of LTCF residents with resistant bacteria included age > 86 years, antibiotic treatment in the previous 3 months, indwelling devices, chronic obstructive pulmonary disease, physical disability, and the particular LTCF unit.

[Gamma interferon testing in blood and cerebrospinal fluid--rapid method for the diagnosis of tuberculous meningitis]. / Dozarea gama-interferonului în sânge si în lichid cefalorahidian--metoda rapida de diagnostic a meningitei tuberculoase.

AIM: To evaluate the benefit of this early method of diagnosis of tuberculous meningitis, gamma-interferon levels comparatively in blood and cerebrospinal fluid (CSF). MATERIAL AND METHOD: We have studied 50 patients with tuberculous meningitis admitted in the Clinic of Infectious Diseases Iasi between 2006-2007, from the epidemiological, clinical, diagnosis and therapeutical points of view. RESULTS: Tuberculous meningitis was more frequent in males, with a mean ration of 2.5. The age of patients varied between 2 and 78 years of age, with a mean value of 30.5 years. 35.6% of patients were children. In 32 cases the meningeal infection was secondary, disseminated from a primary site, most frequently from the lungs (68,7%). The bacteriologic confirmation was through culture in 13.3%, with an average of 23.4 days of incubation. In whole blood the sensitivity Quantiferon TB Gold assay (QTF) was 78.57%. In CSF the specificity was higher than in blood (96.1 vs. 88.4%), having a positive prediction value over 90%. Antituberculous therapy prior to QTF testing had a negative impact, 50 to 6 cases having negative QTF results. CONCLUSION: The performance indicators of TB Gold Quantiferon Test in serum or CSF are high, being more sensitive and rapid than the direct exam of CSF or BK culture.

[Antimicrobial resistance profile of E. coli and Klebsiella spp. from urine in the Infectious Diseases Hospital Iasi]. / Profilul de rezistenta al E. coli si Klebsiella spp. din infectii urinare in Spitalul de Boli Infectioase Iasi.

UNLABELLED: The increasing frequency of extended-spectrum beta-lactamases (ESBLs) producing Enterobacteriaceae among nosocomial and community-acquired infections is an important problem for both microbiologists and clinicians, because of the difficulty in correctly detecting, reporting and treating such infections. RESULTS: In the Clinical Hospital of Infectious Diseases Iasi the most frequent etiological agents of urinary tract infections were: E. coli - 64%, Klebsiella spp. 11% and Enterococcus spp - 5%. The resistance rate of E. coli and Klebsiella spp. was 41% and 60%, respectively to amoxicillin-clavulanic acid, 29.6% and 72.5%, respectively to third generation cephalosporins, 26% and 24%, respectively to ciprofloxacin. The most active antimicrobial agents against cephalosporins resistant strains of E. coli and Klebsiella spp were carbapenems (susceptibility rate 99% and 94%, respectively) and colimycin (susceptibility rate 89% and 83%, respectively).

Antimicrobial susceptibility of Staphylococcus aureus isolated from colonized hospital personnel.

The present study was performed to investigate the in vitro activity of oxacillin and other antimicrobial agents against S. aureus strains obtained from nursing personnel. We tested 127 S. aureus colonizing nasal mucous and hand skin and isolated from nursing personnel of University Hospital Department of Infectious Diseases, Iasi, during June 2005 period. Minimum inhibitory concentrations (MICs) were determined by the dilution method in Mueller-Hinton agar. Most of the S. aureus strains were susceptible to tested agents excepted erythromycin and azithromycin. Erythromycin and azithromycin resistance was observed among 29.1% respectively 22% of S. aureus strains. Vancomycin was active against all isolates. Teicoplanin was active against against all MRSA excepted one of the strain, with an reduced susceptibility. Linezolid has very good in vitro activity against staphylococci, with an MIC 90 of 2 mcg/ml and only 0.8% resistance. The MIC values range was between 0.5-2 mcg/ml. In conclusion, the usually hygienic methods (disposable gowns, hygienic hand disinfection after each patients contact, masks use when is a risk of aerosolization of MRSA) are indicate for significantly reducing of these strains.

[Side effects of antiretroviral therapy]. / Efecte secundare ale terapiei antiretrovirale.

Highly active antiretroviral therapy (HAART) has changed the natural history of HIV infection, but the presence of adverse events may limit its efficacy. Nucleoside reverse transcriptase inhibitors can cause mitochondrial toxicity and anemia, non-nucleoside reverse transcriptase inhibitors are associated with rash and central nervous system disturbance; protease inhibitors elicit gastrointestinal adverse effects and metabolic abnormalities including lipodystrophy syndrome, hyperlipidemia and insulin resistance. These complications have the potential to increase morbidity and mortality significantly in those requiring long-term treatment of HIV-infection. The presence of such abnormalities also has an impact on adherence to treatment. Besides providing health benefits, HAART may have a negative impact on patients' quality of life. Identifying and treating these complications has important implications for patient survival.

[Activity of fourth generation cephalosporins against clinical isolates of Enterobacteriaceae]. / Activitatea cefalosporinelor de generatia a patra asupra unor izolate clinice de enterobacterii.

Cefpirome and cefepime are a novel group of cephalosporins which contain a positively charged quaternary ammonium at carbon 3 of the dihidrothiazone ring. The antimicrobial agents cefpirome, cefepime, cefotaxime, ceftriaxone, ceftazidime, cefoperazone and imipenem were tested against clinical isolates of Escherichia coli (n = 302) and Klebsiella spp. (n = 62) obtained during september-december 2002 from patients of Galati Emergency Hospital. The fourth generation cephalosporins cefpirome and cefepime have similar in vitro activities to the third generation cephalosporins. E. coli showed the comparable resistance rates for all cephalosporins. Against Klebsiella spp. strains cefpirome was less active (35.5% resistance) than cefepime (25.8% resistance). As expected, imipenem had excellent activity (100% susceptibility).

[Possibilities and limits of antiretroviral actual therapy]. / Posibilitati si limite ale terapiei actuale antiretrovirale.

The therapies now approved for HIV-infection inhibit one of two viral-specific enzymes, reversetranscriptase or protease. Combining this drugs into regimes based on at least three individual drugs--so-called HAART--has resulted in a remarkable reduction in HIV-associated morbidity and mortality. Despite these therapeutic advances, many patients are either intolerant of available agents or develop virologic failure. Problems of adherence, drug-resistance, latent reservoirs and drug-induced toxic effects that compromise effective viral control point to need for new strategies (e.g. structured treatment interruptions--STIs) and new classes of anti-HIV drugs with different modes of action (e.g. blocking HIV entry into human cells or fusion process). The use of adjunctive immune-based therapy such as IL-2 may permit more extensive immune restoration.

[Fungal infection in AIDS patients. Consideration for 10 cases]. / Infectia fungica la bolnavii cu SIDA consideratii pe 10 cazuri.

Clinic, etiologic and therapeutic study of fungic infection in AIDS patients. The retrospective clinical study of the 10 AIDS patients admitted between 01.01.1994 and 31.12.2000 in Infectious Diseases Clinical Hospital of Iasi. The majority of the cases (7) were registered in the last 3 years: 4 children and 6 adults. HIV infection was known only for 4 patients according to their history, and for the other 6 patients this diagnosis was made concomitantly of fungic infection diagnosis. The disease onset was insidious in 7 cases (2 children and 5 adults) being characterized by manifestations of nervous system involvement and consciousness disturbances (6 cases). The etiological diagnosis was established for alive patients by cerebrospinal fluid culture and hemocultures and Cryptococcus neoformans was isolated for 9 patients and Candida to another one. Fungic infection lead to meningeal injuries to 6 patients and the systemic one in for 4 patients. Although, under antifungical and antiretroviral therapy, the disease was lethal for 4 patients. The fungic infection recrudesces in AIDS patients, possessing systemic or/and meningeal manifestation, long evolution that can be lethal for a lot of them.