CENTRAL HYPOTHYROIDISM IN SEVERE SEPSIS.

OBJECTIVE: A partial or complete deficiency of hormone secretion by pituitary gland (hypopituitarism) is commonly seen after a pituitary apoplexy caused by an infarction of a pituitary adenoma or pituitary hyperplasia (as in Sheehan's syndrome). Hypopituitarism may also follow surgery, when hypovolemia, anticoagulation, fat/air/bone marrow microemboli can provoke a pituitary infarction/hemorrhage. Other causes of abrupt hypophyseal hypoperfusion, as hypovolemia during a septic shock, could also contribute. In the last mentioned situation, due to the complex endocrine-immune interrelation, sepsis could be masked and improperly managed. CASE REPORT: We report a case of a 72 years-old Caucasian woman, previously healthy, who underwent an orthopedic surgery for a femoral fracture. This event apparently triggered a central-origin hypothyroidism, misinterpreted as "post-surgical psychosis", which, in turn, masked a symptomatology of a subsequent severe sepsis. The patient was admitted in the infectious diseases department with a severe gut-origin sepsis, needing surgery and long course antibiotics. The pituitary insufficiency was reversed. CONCLUSION: Pituitary apoplexy is an uncommon but potentially life-threatening disease, and could be precipitated by successive events - in our case an orthopedic surgery and a subsequent severe sepsis. It needs recognizing (has intrinsic severity and could mask other serious conditions), treat and monitor (could progress and/or reverse).

Safety assessment in Child A cirrhotic patients treated with Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir with Ribavirin.

BACKGROUND: In our country, the national program for hepatitis C virus treatment with ombitasvir/paritaprevir/ritonavir and dasabuvir was approved for patients with stage four of liver fibrosis and stage three associated with specific comorbidities. Our aim was to analyze the characteristics associated with the presence of adverse events in patients receiving this antiviral regimen, with ribavirin in cirrhotic patients. METHODS: We prospectively studied a cohort of adults with hepatitis C virus infection with Child A cirrhosis, treated for 12 weeks with ombitasvir/paritaprevir/ritonavir/dasabuvir and ribavirin, which have been followed in an infectious diseases tertiary-care hospital. RESULTS: We included 137 adult patients diagnosed with compensated cirrhosis, hepatitis C virus genotype 1b infected, 82 (60%) previously treated. We recorded 201 adverse events in 98 (71.5%) patients, with a median number of events per patient of one. The intensity of adverse events was classified as mild, moderate and severe in 50%, 36% and 14% of cases, respectively. Forty-five (22%) episodes required medical intervention. The most frequently reported adverse events were pruritus 34(35%), asthenia 22(22%) and insomnia 15(15%). The presence of severe adverse events was associated with the presence of comorbidities (p = 0.01, OR : 9.5, 95% CI : 1.2-74.3) and with the presence of associated medication (p = 0.02, OR : 3.9, 95% CI : 1.08-14.2). At the end of current treatment, 136 (99.2%) patients had undetectable viral load. CONCLUSION: We found a high number of adverse events, but most of them were mild or moderate and only one quarter of them required medical intervention. Only severe adverse events were associated with comorbidities and associated medication.

The role of tigecycline in the management of Clostridium difficile infection: a retrospective cohort study.

OBJECTIVE: We aimed to compare the outcomes of patients with C.difficile infection (CDI) treated either with tigecycline associated with vancomycin, or with vancomycin alone. METHODS: This single-centre retrospective cohort study included all adults hospitalized from September 2014 through August 2015 for symptomatic, incident CDI confirmed by polymerase chain reaction for C. difficile toxin in stools. The primary outcome was the rate of favourable outcome, defined as a composite of clinical response (resolution of symptoms without need for additional CDI therapy) and achieving discharge without CDI-related surgery or intensive care; a secondary outcome was CDI recurrence. We constructed a non-parsimonious logistic regression model to calculate a propensity score (PS) for those receiving tigecycline. RESULTS: In all, 266 patients were included: 62 patients received both vancomycin and tigecycline, and 204 patients received vancomycin alone. The patients from the two groups were similar regarding demographics and comorbidities but patients in the tigecycline group had a more severe CDI. A favourable outcome in the tigecycline group versus the vancomycin group was found in 50/62 (81%) versus 193/204 (95%). We matched patients receiving tigecycline or not according to the PS and 86 patients (43 pairs) could be matched. The OR for favourable outcome with tigecycline in the matched analysis was 0.92 (95% CI 0.60-1.44; p 0.74). The rate of CDI recurrences was 8/62 (13%) in the tigecycline group versus 39/204 (19%) in the vancomycin group (p 0.2). CONCLUSION: Adding tigecycline to CDI standard therapy did not increase the clinical cure nor reduce the rate of CDI recurrences.

Clinical prediction rule for differentiating tuberculous from viral meningitis.

SETTING: The Professor Dr Matei Bals National Institute of Infectious Diseases, Bucharest, Romania. OBJECTIVE: To create a prediction rule to enable clinicians to differentiate patients with tuberculous meningitis (TBM) from those with viral meningitis. DESIGN: We retrospectively analysed patients admitted to a tertiary care facility between 2001 and 2011 with viral meningitis and TBM. Patients were defined as having TBM according to a recently published consensus definition, and as viral meningitis if a viral aetiology was confirmed, or after ruling out bacterial, fungal and non-infectious causes of meningitis. RESULTS: We identified 433 patients with viral meningitis and 101 TBM patients and compared their clinical and laboratory features. Multivariable analysis showed a statistically significant association between TBM and the following variables: duration of symptoms before admission of ≥5 days, presence of neurological impairment (altered consciousness, seizures, mild focal signs, multiple cranial nerve palsies, dense hemiplegia or paraparesis), cerebrospinal fluid/blood glucose ratio < 0.5 and cerebrospinal fluid protein level > 100 mg/dl. We propose a diagnostic score based on the coefficients derived from the logistic regression model with a sensitivity and specificity for TBM of respectively 92% and 94%. CONCLUSIONS: Our study suggests that easily available clinical and laboratory data are very useful for differentiating TBM from other causes of meningitis.

Isolated tuberculous tenosynovitis of the forearm in an immunocompetent patient.

Primary tuberculous tenosynovitis is a rare manifestation of extraspinal musculoskeletal tuberculosis. The diagnosis may be easily delayed because of its nonspecific clinical signs. We report a case of culture-proven tuberculous tenosynovitis of the extensor carpi ulnaris tendon and common extensor tendon in a 68-year-old female without concomitant pulmonary tuberculosis, nor documented immunodeficiency. The diagnosis was initially overlooked due to the lack of appropriate histological and bacteriological analyses and the lesion recurred after surgery. MR imaging represents the most accurate method in making the diagnosis, but has no diagnostic specificity in regard to tuberculosis, therefore surgical biopsy is strongly recommended. The patient had a favorable clinical response after a combination of excision and appropriate antituberculous therapy for sensitive Mycobacterium tuberculosis. We emphasize the need for an increased awareness and high index of suspicion of tuberculosis in all cases of a chronic orrecurrent abscess in the extremities, not only in patients living in endemic areas but also in those who have emigrated from regions with a high prevalence of tuberculosis.

Detection of Mycobacterium tuberculosis resistance mutations to rifampin and isoniazid by real-time PCR.

OBJECTIVE: The objective of our study was to evaluate the use of a real-time polymerase chain reaction (PCR)-based technique for the prediction of phenotypic resistance of Mycobacterium tuberculosis. MATERIALS AND METHODS: We tested 67 M tuberculosis strains (26 drug resistant and 41 drug susceptible) using a method recommended for the LightCycler platform. The susceptibility testing was performed by the absolute concentration method. For rifampin resistance, two regions of the rpoB gene were targeted, while for identification of isoniazid resistance, we searched for mutations in katG and inhA genes. RESULTS: The sensitivity and specificity of this method for rapid detection of mutations for isoniazid resistance were 96% (95% CI: 88% to 100%) and 95% (95% CI: 89% to 100%), respectively. For detection of rifampin resistance, the sensitivity and specificity were 92% (95% CI: 81% to 100%) and 74% (95% CI: 61% to 87%), respectively. The main isoniazid resistance mechanism identified in our isolates is related to changes in the katG gene that encodes catalase. We found that for rifampin resistance the concordance between the predicted and observed phenotype was less than satisfactory. CONCLUSIONS: Using this method, the best accuracy for genotyping compared with phenotypic resistance testing was obtained for detecting isoniazid resistance mutations. Although real-time PCR assay may be a valuable diagnostic tool, it is not yet completely satisfactory for detection of drug resistance mutations in M tuberculosis.

Type-specific herpes simplex virus-1 and herpes simplex virus-2 seroprevalence in Romania: comparison of prevalence and risk factors in women and men.

OBJECTIVE: To determine herpes simplex virus (HSV)-2 and HSV-1 seroprevalence in women and men in Romania. METHODS: A cross-sectional seroprevalence survey was conducted between 2004 and 2005 on a total of 1058 women and men representative of the population of Bucharest. All participants were aged 15-44 years and completed a structured questionnaire. A blood sample was collected to detect IgG anti-HSV-1 and HSV-2 serum antibodies using the HerpeSelect ELISA (Focus Diagnostics). RESULTS: A total of 761 women (median age 29 years) and 297 men (median age 29 years) were included. Overall, HSV-2 seroprevalence (15.2%) increased with age. Among women, HSV-2 seroprevalence increased from 11.0% in 15-19-year-olds to 38.3% in 40-44-year-olds. Among men, seroprevalence increased from 4.0% in 20-24-year-olds to 27.1% in 40-44-year-olds. HSV-2 seroprevalence was significantly higher among women than men (17.0% vs. 10.8%). HSV-1 seropositivity was high (87.2%) in all age groups, with no clear trend by age or by sex. In addition to older age and female sex, risk factors for HSV-2 included greater number of lifetime sexual partners, lower educational attainment, and history of genital vesicles. Lower educational level and rural residence were associated with a higher risk of HSV-1 seropositivity. CONCLUSIONS: In Romania, HSV-2 seroprevalence was higher in women than men, and was within European limits and lower than that in Africa and the USA. In contrast, HSV-1 seroprevalence was generally higher than that previously recorded in similarly aged populations in Western Europe.

Seroprevalence of Borrelia burgdorferi in Romania.

In order to assess the seroprevalence of Borrelia burgdorferi in Romania and to define associated risk factors, a cross-sectional, observational study was performed in 13 districts during 1999. Sera from healthy blood donors (1,598) and from forestry workers (1,048) were tested. A two-step testing strategy was used in which sera were tested for anti-B. burgdorferi antibodies by a commercially available passive hemagglutination assays (PHA). All PHA positive sera were then evaluated by Western blot IgG. Demographic data regarding age, sex, profession, work place/residence, duration of employment (forestry workers), animals in the environment, and tick bites history were collected using a questionnaire. Data obtained from serological study were matched with that obtained from the questionnaire. The seroprevalence of B. burgdorferi in blood donors was of 4.3% (range 1.4-8.7%) and 9.3% (range 2.8-31.7%) in forestry workers. Seroprevalence was higher in forestry workers with a tick bite history (10.7 vs. 4.3%, p < 0.05). The highest seroprevalence in blood donors (8.7%) was noted in Maramures, a northern district of the country, whereas in forestry workers the highest seroprevalence (31.7%) was observed in a western district (Arad), where a previous study in entomology has demonstrated the highest density of Ixodes ricinus ticks in Romania.

[The epidemiology of Lyme borreliosis]. / Epidemiologia boreliozei Lyme.

Lyme borreliosis (LB) is a multisystem disease caused by infection with Borrelia burgdorferi sensu lato (B.b). LB is the most common human tick-borne disease, transmitted principally by species of Ixodes ricinus in Europe, I. persulcatus in Eurasia, I. scapularis and I. pacificus in North America. B.b has been isolated or detected in 24 different species of mammals or birds. The B31 strain of B.burgdorferi sensu stricto is predominant in United States and in Europe B. garinii, B. afzelii and B. burgdorferi sensu stricto.

The combined value of chemoprophylaxis and pneumococcal vaccine in the prevention of recurrent pneumococcal meningitis.

We report the case of an immunocompetent patient who has been the subject of 39 episodes of recurrent pneumococcal meningitis over a 20 year period. The recurrences of bacterial meningitis due to cerebrospinal fluid leakage and the presence of chronic sinusitis were not influenced by the surgical repair of a fistula and the repeated surgical draining interventions on suppurating chronic sinusital foci. Phenoxymethylpenicillin treatment reduced the number of recurrences and the combination of pneumococcal vaccine and penicillin prophylaxis allowed a 5 year period free of any recurrences.