Diagnostic Dilemmas in Hepatitis C Virus Infection for Hemodialysis Patients.

BACKGROUND: Hepatitis C virus (HCV) is a leading cause of chronic hepatitis in dialysis patients. The diagnosis of HCV infection in these patients is predominantly based on laboratory tests because of the specificity of the clinical course of the disease. AIM: The present prospective study aimed at determining very accurately the prevalence rate of HCV infection in patients on dialysis by simultaneously testing them for anti-HCV and for HCV RNA levels. MATERIALS AND METHODS: For the present cross-sectional longitudinal study we recruited and followed up 93 patients from St George University Hospital Hemodialysis Unit between July 2013 and December 2014. All patients were tested for anti-HCV and HCV RNA. The anti-HCV negative patients were tested for anti-HCV and HCV RNA at least twice at intervals of 6 months or more (up to 12 months). Anti-HCV antibodies were identified using a third generation ELISA assay. Commercial kits for real-time polymerase chain reaction (RT-PCR) were used to detect HCV RNA in the plasma and mononuclear cells. Aminotransferase and gammaglutamyl transpeptidase levels were studied to find if liver inflammation was present. RESULTS: The total seroprevalence in 68 patients was 20.6% (14). Of these, 10 patients were viremic (HCV RNA+/anti-HCV+), and 4 patients (5.9%) had discordant results (anti-HCV+/HCV RNA-). Acute hepatitis was detected in one patient. Duration of dialysis in HCV viremic patients was longer than that in aviremic patients (p=0.005). CONCLUSIONS: The present study suggests that HCV infection in dialysis patients can be diagnosed more accurately if these patients are tested using two diagnostic methods - a serological test and a biomolecular assay. Further studies with larger sample size may prove the feasibility of such approach for all dialysis patients in this country.

Lethality among Patients with HIV/AIDS Monitored in the Clinic of Infectious Diseases in St George University Hospital, Plovdiv, 2010-2014.

BACKGROUND: The introduction of complex antiretroviral therapy has resulted in signifi cant decrease in the mortality rate of HIV positive patients, but it still remains unacceptably high, especially in some groups of patients. AIM: To investigate the death rate in patients with HIV/AIDS, lethality and mortality in co-infection, and the most common causes and predictors of fatal outcome, focused on early diagnosis and appropriate therapy. MATERIALS AND METHODS: The study included 53 deceased patients with HIV/AIDS, monitored at the Clinic of Infectious Diseases in St George University Hospital, Plovdiv between 01.01.2010 and 31.12.2014. The methods of research included clinical analysis, laboratory tests, microbiological and serological tests (HCV, HBV, toxoplasmosis), ELISA, PCR. Statistical analysis was performed by descriptive statistics, the Student's t-test, the method of Van der Ward, and regression analysis (logistic regression). RESULTS: During the study period 316 patients with HIV/AIDS were monitored, 53 of them with lethal outcome. Lethality was 16.7% for the whole group; in intravenous drug users - 13.8%; in co-infected patients: HIV/M. tuberculosis - 46%, in HIV/HCV - 17.8%. Lethality and mortality in HIV(+) patients with co-infections in populations of diff erent age, gender, duration since starting сАRТ and degree of immunodefi ciency (according to CD4, VL) was compared with the lethality and mortality in patients with these conditions from the general population. CONCLUSIONS: Fatal outcome in patients with HIV/AIDS was most commonly associated with co-infections HIV/M. tuberculosis and HIV/HCV. Predictors of a fatal outcome are pulmonary tuberculosis, advanced immunodefi ciency with VL> 500 000 c/µL and CD4 <100/mm3, absence or non-systemic antiretroviral therapy.

Cholestatic syndrome in viral hepatitis A.

AIM: To study the cholestatic forms of viral hepatitis A that are described as unusual and very rare, but that are of great significance because of their severe course and high morbidity rate. MATERIAL AND METHODS: We describe herein 17 cases of hepatitis A virus (HAV) infection with pronounced cholestasis treated in the Clinic of Infectious Diseases at St. George University Hospital between 2002 and 2006. They are taken from a contingent of 820 patients we studied in the course of the research: of these 400 were cases of sporadic disease and 420 patients were involved in an epidemic outbreak of the disease. All got this diagnosis based on an anti-HAV/IgM test. Eight parameters were analyzed: age, max TBil, max ALT, ALP, GGT, no urobilinogen in urine, ultrasound monitoring of hepatomegaly, and hospital stay. RESULTS: The 17 patients we discuss here are 2.07% of the total 820 patients with viral hepatitis A (VHA). In 14 the disease had a cholestatic component; 3 cases were a cholestatic form of the disease. The mean hospital stay was 49.1 +/- 11.5 days, the longest--75 days. The hyperbilirubinemia had high levels at the disease climax - the mean concentration was 356.6 microkmol/l, and remained greater than 150 microkmol/l for more than a month. In 10 patients (58.2%) transaminase activity was over 1400 U/l, (mean 2011 U/l). CONCLUSION: Viral hepatitis A ran with cholestatic syndrome in 2.07%; 23.5% of these cases were classified as severe forms of the disease and 76.5%--as moderate. This is evinced by the enhanced transaminase activity, the elevated TBil, pronounced intoxication, the adynamia, vomiting, headache, the vertigo, all of these items in the objective severity score system we used.

Prevalence of cytomegalovirus infection in hospitalized infants.

UNLABELLED: Data on cytomegalovirus infection (CMV) prevalence and course in hospitalized infants are rather scarce, obsolete and considerably inconsistent. AIM: to determine the prevalence, rate of clinical manifestations, risk factors and predictive capacity of clinical manifestations of CMV infection in hospitalized infants during their first year of life. PATIENTS AND METHODS: All 163 infants hospitalized in the Pediatric Ward for Nonrespiratory Pathology in a tertiary hospital were serologically screened for cytomegalovirus infection for 10 months. In infants up to 6 months old that were CMV IgG (+) and CMV IgM (-) we followed up the CMV IgG concentration or compared it with that of their mothers. RESULTS: The CMV prevalence for the entire study sample was 33.1 +/- 3.7% (54 seropositive out of 163 examined infants); in newborns it was 19.4 +/- 6.7% (7 of 36), in infants aged 1-3 months--23.8 +/- 5.4% (15 of 63), in 4-6-month olds--28.1 +/- 8.1% (9 of 32), and in 7-12-month old--71.9 +/- 8.1% (23 of 32). The rates of clinically apparent infections in the respective groups was 33.3 +/- 6.5%, 57.01 +/- 20.2%, 53.3 +/- 13.3%, 33.3 +/- 16.6%, and 13.0 +/- 7.17%. The overall rate of clinically apparent CMV infection in all 163 children was between 11.0 +/- 2.5% and 17.2 +/- 2.9%. The probability of CMV infection increased with age and duration of breastfeeding. Hepatitis, cerebral vasculopathy and pneumonia (alone or combined) turned out to be predictors of CMV infection, but none of these symptoms had a frequency greater than 22%. CONCLUSIONS: We found a high rate of cytomegalovirus infections in hospitalized infants less than one year of age. This infection is the reason why at least 10% of the newborns and 12% of the children aged 1 to 3 months were hospitalised. The course was clinically apparent in over half of the infected children of up to 3 months of age.

Relative share of asymptomatic forms of hepatitis a in Plovdiv region, Bulgaria.

OBJECTIVE: To study the relative share of asymptomatic forms of Hepatitis A in family reservoirs of infection with different hygienic conditions. MATERIALS AND METHODS: Asymptomatic forms were identified by detecting anti-HAV IgM using ELISA. Two types of households: with poor hygiene and with good hygiene, were studied. The study was designed as case-control. A group of Hepatitis A contact children attending day nurseries and kindergartens was also included in the study. RESULTS: The relative share of asymptomatic forms of HAV infection in poor hygiene households was 58.62%, while in those with good hygiene it was 41.57%. The comparison using Fisher's exact test yielded OR = 1.99 and 95% CI (P < 0.05). Asymptomatic forms were found in 7.75% of the investigated contacts among children attending day nurseries and kindergartens. CONCLUSION: Asymptomatic forms of hepatitis A are very common which makes them epidemiologically quite significant as many of the cases remain unrecognized and later become focal points of new cases of the disease. Poor hygiene conditions are likely to cause more asymptomatic forms. The high relative share of asymptomatic forms found in the households supports the need for immunoprophylaxis of the contacts.

Seroprevalence of hepatitis A viral infection in Plovdiv, Bulgaria.

INTRODUCTION: Hepatitis A occurs throughout the world, albeit with different endemicity. The level of endemicity is determined for each country from the annual incidence rate and from the age-specific seroprevalence of anti-HAVt. AIM: To assess the anti-HAVt seroprevalence in 180 people with no hepatitis A history. The study also aimed at determining the susceptibility of the separate individuals to the disease. PATIENTS AND METHODS: Two groups of people with no history of hepatitis A were studied; the study subjects were randomly selected from two quarters of Plovdiv--one with poor hygienic and sanitary conditions and the other with normal ones. The study was performed using Dia Sorin kits and equipment. RESULTS: Ninety-three subjects were included in Group I; 84 (90.23%) of these were anti-HAVt positive. Group II included 87 subjects of which 39 (44.83%) tested positive. The mean anti-HAVt seroprevalence for the whole sample (n=180) was 68.33%. CONCLUSIONS: The established mean seroprevalence of anti-HAVt is typical for countries with intermediate level of hepatitis A endemicity. The epidemiology of the disease, however, is completely different for each one of the groups. This finding makes it necessary that different preventive approach be used for each one of these groups, specifically related to the individual susceptibility to the disease--something that is not done in everyday practice.

Booster immunity - diagnosis of chronic hepatitis B viral infection.

INTRODUCTION: Diagnosis of chronic hepatitis B virus (HBV) infection particularly its occult form requires monitoring and repeat serological and molecular studies. The aim of the study was to investigate the possible relation between the case of a family outbreak of hepatitis A and the finding that a member of this family was diagnosed with chronic hepatitis B. METHODOLOGY: A mother and her two sons, one previously diagnosed with chronic HBV infection, were hospitalized due to suspected acute hepatitis. Serological markers for hepatitis A, hepatitis B and hepatitis C were assessed. Additionally, HBV DNA was tested with a sensitive PCR. Hepatitis B vaccine was administered to the mother to differentiate resolved from occult HBV infection. RESULTS: A family outbreak of hepatitis A was confirmed, alongside a focus of chronic HBV infection. The serological profile for two brothers was HBsAg(+), anti-HBcIgM(-), anti-HBc(+), HBcAg(-)/anti-HBe(+). The mother was negative for all HBV markers except anti-HBc. HBV DNA was detected at a level of 461 IU/mL in the elder brother, 3647 IU/mL in the younger brother and was negative in the mother on two occasions. Her anti-HBc alone, having two sons with chronic HBV infection, and her lack of antibody response to hepatitis B vaccine despite being negative for HBV DNA, led to the diagnosis of probable occult HBV infection. CONCLUSION: Our results confirmed that a vaccination approach could facilitate diagnosis of chronic HBV infection in the presence of isolated anti-HBc. If it were not for a family outbreak of hepatitis A, this unexpected family HBV focus would not have been revealed.