The Challenging Anticoagulant Therapy in COVID19 Patient with Associated Coagulopathy.

COVID-19 became a widespread infectious disease in late 2019. Indonesia currently has the highest COVID-19 mortality rate in Asia, between 4-5 percent. Interestingly, COVID-19-associated coagulopathy characterized by an increase of several procoagulant factor levels, including fibrinogen and D-dimer, that has been associated with higher mortality and unfavorable outcomes. We report a case of a 30-year-old male admitted to the hospital with a profuse vomiting and worsening fever, cough and shortness of breath, and was diagnosed with COVID-19-associated coagulopathy. Seven days after admission, he became deteriorated with significant reduction of oxygen saturation and his coagulation parameter levels were increased with highly suspicion of pulmonary embolism. He was treated with azithromycin, isoprinosine, lopinavir, and fondaparinux with thromboprophylaxis dosage since admission. The role of increased fondaparinux dosage at the time of clinical deterioration was then followed by clinical improvement and reduced D-dimer level. Anticoagulant therapy, mainly with fondaparinux, showed a better prognosis in patients with markedly elevated D-Dimer. Fondaparinux needs to be monitored appropriately to prevent bleeding and adverse. The patient was discharged from the hospital in an improved condition and normal D-Dimer levels. There was no bleeding event nor other major side effects had been found in this case. The decision for increasing dose of anticoagulant may be determined on individual basis, considering risks, benefits, and also the most important is clinical findings.

Development, Validation, and Application of the LC-MS/MS Method for Determination of 4-Acetamidobenzoic Acid in Pharmacokinetic Pilot Studies in Pigs.

Each drug has pharmacokinetics that must be defined for the substance to be used in humans and animals. Currently, one of the basic analytical tools for pharmacokinetics studies is high-performance liquid chromatography coupled with mass spectrometry. For this analytical method to be fully reliable, it must be properly validated. Therefore, the aims of this study were to develop and validate a novel analytical method for 4-acetamidobenzoic acid, a component of the antiviral and immunostimulatory drug Inosine Pranobex, and to apply the method in the first pharmacokinetics study of 4-acetamidobenzoic acid in pigs after oral administration. Inosine Pranobex was administered under farm conditions to pigs via drinking water 2 h after morning feeding at doses of 20, 40, and 80 mg/kg. For sample preparation, we used liquid-liquid extraction with only one step-protein precipitation with 1 mL of acetonitrile. As an internal standard, we used deuterium labeled 4-acetamidobenzoic acid. The results indicate that the described method is replicable, linear (r2 ≥ 0.99), precise (2.11% to 13.81%), accurate (89% to 98.57%), selective, and sensitive (limit of quantitation = 10 ng/mL). As sample preparation requires only one step, the method is simple, effective, cheap, and rapid. The results of the pilot pharmacokinetics study indicate that the compound is quickly eliminated (elimination half-life from 0.85 to 1.42 h) and rapidly absorbed (absorption half-life from 0.36 to 2.57 h), and that its absorption increases exponentially as the dose is increased.

Selected leukocyte subpopulations in peripheral blood and uterine washings in cows before and after intrauterine administration of cefapirin and methisoprinol.

The aim of the study was to evaluate the selected lymphocyte subpopulations TCD4, TCD8, BCD21, BCD25, CD18, CD11b, and MHC II in blood and uterine flush of cows with endometritis, before and after intrauterine (i.u.) administration of cefapirin and methisoprinol. The research was carried out on 28 cows with clinical endometritis. Animals were divided into four groups, each composed of seven cows, depending on the i.u. preparation used: Group A, cefapirin; Group B, methisoprinol; Group C, cefapirin and methisoprinol simultaneously; and a control group-without medication. The study was performed using flow cytometry method. Summarizing the results of the research, i.u. infusion of cefapirin caused a weakening of the effector phase of the local uterine immune response; however, it enhanced leukocyte chemotaxis and antigen presentation. After i.u. administration of methisoprinol, the stimulation of specific uterine immunity mechanisms was mainly observed. The use of both mentioned preparations showed the strengthening of specific uterine immunological mechanisms presumably caused by methisoprinol, despite the inhibitory effect of the antibiotic. Intrauterine use of immunostimulatory substances can improve the effectiveness of the endometritis treatment in cows by improving specific local mechanisms of uterine immunity. As a consequence, it may enhance the effector function of immune competent cells and finally eliminate inflammation.

Phagocytic and oxidative burst activity of phagocytic cells in peripheral blood and uterine washings in cows with clinical endometritis before and after intrauterine use of cephapirin and methisoprinol.

The aim of the study was to evaluate phagocytic and killing activity of phagocytic cells in blood and uterine flush of cows with endometritis before and after intrauterine (i.u.) administration of cephapirin and methisoprinol. The research was carried out on 28 cows with clinical endometritis. Animals were divided into four groups, each composed of seven cows, depending on the i.u. treatment used: Group A-cephapirin; Group B-methisoprinol; Group C-cephapirin and methisoprinol at the same time; and a control group-without medication. Using flow cytometry technique, the phagocytic activity of granulocytes and monocytes was identified, as well as the oxidative burst activity of neutrophils in the peripheral blood and uterine washings. Summarizing the results of the research, i.u. infusion of cephapirin caused a reduction in the phagocytic and killing activity of phagocytes. The i.u. use of methisoprinol increased phagocytic and killing activity of phagocytes in the uterus. Administering both listed substances simultaneously showed a decrease in phagocytosis, presumably due to the dominating inhibitor effect of the antibiotic. However, also an increase of mean fluorescence intensity was observed, presumably caused by the methisoprinol. Intrauterine use of immunostimulatory substances, can improve the effectiveness of the treatment of endometritis in cows.

[EFFECTIVENESS OF COMBINED TREATMENT OF HPV INFECTION].

This study evaluates the effectiveness of immunomodulating drug isoprinosine in a comprehensive treatment of genital warts in men. Most of the patients were aged 20-30 years. The combination therapy was found to have long term effectiveness. In the group of patients undergoing only destructive methods of treatment relapse after 8 month follow-up was diagnosed in 32% and in patients of the combination therapy group (destruction plus isoprinosine) - in 7% of patients. The pharmacological action of the drug (immunostimulating, antiviral) and the effectiveness of its combination with destructive therapies justify the use of inosine pranobex (isoprinosine) both in the complex therapy of genital warts and for the prevention of the disease recurrence.

Immunomodulatory effects of inosine pranobex on cytokine production by human lymphocytes.

Inosine pranobex (inosine dimepranol acedoben, isoprinosine) (Inos) is an immunomodulatory and antiviral drug used in some viral infections, especially in patients with weakened immunity. In the present study, effects of Inos on the production of cytokines attributable to Th1 (IL-2, IFN-g, and TNF-a) or Th2 cells (IL-4, IL-5, and IL-10) were tested in human peripheral blood lymphocyte cultures stimulated with phytohemagglutinin (PHA). Inos enhanced TNF-a secretion significantly (in short-term--24-hour, and prolonged term--72-hour cultures) and IFN-g (in 72-hour cultures). Surprisingly, production of IL-10 by PHA-stimulated lymphocytes was suppressed by Inos in a dose-dependent manner in both 24-hour and 72-hour cultures. These results shed some light on immunomodulatory properties of Inos and suggest applicability of this agent in patients with a depressed function of the immune system.

[The role of human papilloma virus in development of chronic urethritis and vulvodynia in females: perspectives of immunomodulating therapy].

The article is devoted to combined affection of the lower urinary tracts and genitalia in women with human papilloma virus (HPV) infection which manifests with persistent recurrent urethritis, pelvic pain syndrome. The colposcopic and urethrocystoscopic features, disturbed microcirculation of urethral and vaginal mucosa in virus infection promoting recurrences and persistence of HPV are discussed. Immunomodulators (inosin pranobex-groprinosin) are recommended for more effective treatment.

The effect of different doses of methisoprinol on the percentage of CD4+ and CD8+ T lymphocyte subpopulation and the antibody titers in pigeons immunised against PPMV-1.

As immunosuppression in pigeons is common and results in reduced post-vaccination immunity and lower health status of the birds, studies have been taken up aimed at evaluation of the effect of three doses of methisoprinol on the percentage of CD4+ and CD8+ T lymphocyte subpopulation in peripheral blood and in the spleen and the titre of anti-NDV antibodies in the serum of pigeons in four groups (A, B, C, D), with 20 birds each. Pigeons in each group were immunised against paramyxovirosis at week 6 and 9 of life. Water for injection (group A - control) or methisoprinol at 100 mg/kg of body weight (group B), 200 mg/kg of body weight (group C) and 600 mg/kg of body weight (group D) was administered intramuscularly for 3 days before each vaccination. The immunological analyses were carried out by flow cytometry and the ELISA test. The findings indicate that methisoprinol administered intramuscularly at 100 and 200 mg/kg of body weight for 3 successive days before vaccination against paramyxovirosis mainly stimulates the mechanisms of non-specific humoral and cellular immunity, which is indicated by a higher percentage of the subpopulation of CD4+ T lymphocytes in peripheral blood and in the spleen and a higher titre of anti-NDV antibodies.

The influence of methisoprinol administered in ovo on the morphological structure of the spleen in turkeys.

This study analyzed the effect of a synthetic, low-toxic immunomodulator - methisoprinol - administered in ovo on the morphological structure of the spleen in turkeys. Experiments were conducted on three groups of 5-day-old BUT 9 turkeys (35 birds in each group) hatched from eggs which, on day 26 of incubation, had been administered methisoprinol (VetAgro, Lublin, Poland) in ovo in a dose of 5 mg (group I) or 20 mg per egg (group II). Poults hatched from eggs administered a physiological solution of NaCl in a dose of 0.1 ml per egg in ovo served as a control (group III). Samples of the spleen were collected from 5 birds selected at random from a group of decapitated 5-day-old poults and the prepared 7 fm-paraffin sections were stained with HE. A morphometric analysis of the germinal centres of the white pulp of the spleen was conducted by subjecting pictures taken with an optical microscope to a Digital Image Analysis using Axio Vision software (by Zeiss). The study demonstrated that in terms of the morphological structure, the spleen of the poults hatched from eggs administered 5 mg of methisoprinol (group I) did not differ considerably from the spleen of the control birds. In turn, spleens of the poults hatched from eggs administered 20 mg of methisoprinol per embryo were characterized by distinctively developed red pulp and within the area of the white pulp by distinct cortical section containing numerous lymphocytes. In spleens of the poults from this group, the morphometric examination also demonstrated a higher number of germinal centres of the white pulp as compared to their number in spleens of the birds from the other groups.

Isoprinosine affects serum cytokine levels in healthy adults.

Isoprinosine is a synthetic purine derivative with immunomodulatory and antiviral properties, which result from an apparent in vivo enhancement of host immune responses. To evaluate the serum levels of certain cytokines during and after isoprinosine treatment, we assigned 10 healthy volunteers to receive isoprinosine 1 g, 3 times daily, 5 consecutive days weekly. Both treatment and follow-up phase last 3 weeks. Interferon-gamma (IFN-gamma), interleukin-2 (IL-2), IL-10, and tumor necrosis factor-alpha (TNF-alpha) were measured in serum using commercial ELISA kits at baseline, 7th, 10th, 14th, 21st, 28th, 35th, and 42nd day. We observed an increase in serum levels of all measured cytokines at 7th to 10th day. The levels of IL-2 had another raise at 42nd day after drop to initial values (P < 0.05; P < 0.001, respectively). Those of IL-10 held up enhanced from 7th to 28th day of measurement (P < 0.01). There was a nearly flat line of values of TNF-alpha after initial slight increase at 10th day. We found a moderate negative correlation between IFN-gamma and IL-2, IL-10, and TNF-alpha (Spearman's r: -0.63, -0.62, -0.63; P < 0.05, respectively). We have demonstrated the immunomodulating properties of isoprinosine in healthy adults. It suggests resumption of the research with up-to-date methods to elucidate the mechanisms of action of inosine pranobex and maybe the other inosine compounds in different clinical settings.

The influence of methisoprinol applied in ovo upon hatchability and health status of turkeys.

A study was undertaken to determine the effect of a synthetic immunomodulator, i.e. methisoprinol applied in ovo, upon the hatchability of turkey poults under conditions of a standard hatchery as well as on their health status evaluated based on analyses of selected biochemical indices in their blood serum. Experiments were conducted on 5 groups of BUT 9 turkeys at the age of 5 days (35 birds in each group) hatched from eggs to which methisoprinol (VetAgro, Lublin, Poland) was applied in ovo at a dose of 5 mg (group I), 10 mg (group II) or 20 mg per egg (group III) on the 26th day of incubation. Turkeys hatched from eggs to which a physiological solution of NaCl was applied on the same day at a dose of 0.1 ml per egg (group IV) as well as those hatched from eggs without in ovo injection (group V) served as controls. Five hundreds eggs were used in each group. Hatchability was evaluated based on the number of hatched poults in respect of the number of eggs with live embryos transferred from the setting compartment to the hatching compartment, that were subjected to in ovo administration of the preparations according to the experimental design. Blood serum of the 5-day-old turkey poults was analyzed for activities of AST, ALP, LDH-L, CK, lysozyme and ceruloplasmine as well as for total protein and albumin contents. Analyses were also conducted for the immune system organ index - percentage contribution of organs of the immune system (spleen, thymus and the bursa of Fabricius) in the body weight of turkeys. The study demonstrated that methisoprinol administered to turkey embryos in ovo on day 26 of incubation at doses of 5, 10 or 20 mg per embryo did not induce any disturbances in the hatching process or affect its final result. In addition, it was shown not to exert any negative effect on the health status of the reared turkey poults.

Subacute sclerosing panencephalitis.

Subacute sclerosing panencephalitis (SSPE) is a subacute encephalopathy of childhood and young adolescence. Infrequently, SSPE can occur in adults and pregnant women. It is caused by an aberrant measles virus, known as the SSPE virus. SSPE virus differs from wild-type measles viruses in the form of several mutations affecting the viral genome. The matrix gene is most commonly affected by these mutations. The characteristic clinical manifestations of SSPE include behavioral changes, cognitive decline, myoclonic jerks, seizures, abnormalities in vision, bilateral pyramidal signs and coma. Ocular changes may occur in up to 50% of patients. The most characteristic ophthalmological lesion is necrotizing retinitis. Cortical blindness can be the early feature of SSPE. The diagnosis of SSPE is often difficult in the early stages. In a typical case diagnosis is based on clinical, electroencephalographic, and cerebrospinal fluid findings. At present, there is no effective treatment to completely cure SSPE. Oral isoprinosine and intrathecal or intraventricular alpha-interferon may prolong survival to some extent. Immunization against measles is currently the most effective strategy against SSPE.

Long-term follow-up of patients with adult-onset subacute sclerosing panencephalitis.

Subacute sclerosing panencephalitis (SSPE) is a rare infectious central nervous system disease with a poor prognosis. Nineteen patients, 18 males and one female, ranging in age from 18 to 22, mean 19.6+/-1.5 years with SSPE were evaluated. We treated 9 patients with oral isoprinosine and 10 patients with alpha-interferon plus oral isoprinosine and followed up for 16 to 160 months. Of the 9 patients treated with oral isoprinosine, 7 (77.7%) died, one stabilized, and one showed progression. Seven (70%) of 10 patients treated with alpha-interferon plus oral isoprinosine died, one showed progression, and stabilization was observed in two patients. Thus, we suggest that isoprinosine alone or in combination with intraventricular interferon did not change the prognosis in long-term follow-up periods.

[Therapy and prognosis in subacute sclerosing panencephalitis].

Subacute sclerosing panencephalitis (SSPE) is a progressive and fatal central nervous system disorder that results from a persistent SSPE virus infection. Compound which inhibits the replication of SSPE virus might be a candidate for the specific drug for SSPE. Out of several compounds which had been tried for the treatment of SSPE, two drugs, i.e., inosiplex and interferon-a were reported to be effective. Those drugs, however, could not cure the disease. Recently, ribavirin therapy has been proposed as novel antiviral chemotherapy for SSPE. By intraventricular administration, ribavirin level in CSF reaches a concentration at which ribavirin could completely inhibit the replication of SSPE virus. Thus, intraventricular ribavirin therapy might eradicate SSPE virus from the CNS and stop the progression of SSPE syndrome. The therapeutic efficacy should be evaluated in the patients who are treated with the therapy at an early stage of SSPE.

Inosiplex for treatment of alopecia areata: a randomized placebo-controlled study.

Treatment of alopecia areata remains unsatisfactory. We decided to test if systemic therapy with inosiplex (Isoprinosine(R)), an immunomodulator could influence the disease. Thirty-two subjects with recalcitrant alopecia areata, aged 16-48 years (mean 30.3+/-5.1 years), were randomized into two treatment groups of 16 subjects each. They were assigned to receive either oral inosiplex (group 1), or placebo (group 2) on a double-blind basis. Inosiplex dosage was 50 mg/kg/day in five divided doses for 12 weeks. Of the 15 evaluable patients in group 1, 5 (33.3%) had full remission, 8 (53.3%) responded partially and 2 (13.3%) did not respond. Of the 14 evaluable patients in the placebo group, none had full remission, 4 (28.5%) responded partially and 10 (71.4%) did not respond. The therapeutic difference between patients receiving active and placebo therapy was statistically significant (?2=7.82, p<0.01). Compared with placebo, oral inosiplex showed considerable efficacy in alopecia areata with insignificant side-effects. Larger studies are required, however, before inosiplex may be recommended as an efficacious and safe alternative systemic form of therapy for recalcitrant alopecia areata.

Oral inosiplex in the treatment of cervical condylomata acuminata: a randomised placebo-controlled trial.

Conventional therapies for human papillomavirus infection aim to remove clinically apparent lesions, while latent infection may remain, representing a threat for transmission and carcinogenesis. The use of a systemic agent may more effectively control the virus. We conducted a randomised placebo-controlled study to investigate the efficacy and safety of oral inociplex in the treatment of cervical condylomata acuminata (CA) that had been resistant to conventional therapies. Thirty-eight white European women, aged 20-43 years, with genital warts of the cervix, refractory to at least one conventional therapy, were randomly assigned to receive either inosiplex, 50 mg/kg daily peros for 12 weeks (group 1), or placebo (group 2). Of the 17 evaluable group 1 women, 4 responded to the treatment completely, 7 responded partially and 6 did not respond. Of the 19 group 2 women, none responded to the treatment completely, 3 responded partially and 16 did not respond. The therapeutic difference between women receiving active and placebo therapy was statistically significant (chi(2)= 6.69, P < 0.01) and remained significant when an intention-to-treat analysis was performed (chi(2)= 7.69, P < 0.01). None of the complete responders experienced recurrence during the 12-month follow up. Adverse effects were mild and resolved upon completion of therapy. Compared with placebo, inosiplex showed considerable efficacy with insignificant and reversible adverse effects and without recurrences. Inosiplex may represent an efficacious and safe alternative systemic form of therapy for cervical genital warts.

Role of CSF serology in follow-up of subacute sclerosing panencephalitis patients on treatment.

Subacute sclerosing panencephalitis (SSPE) is a progressive inflammatory disease of the central nervous system with poor prognosis and high mortality. No effective treatment has a proven role; oral isoprinosine and intrathecal administration of alpha-interferon may prolong survival. We report an unusual case of adult onset SSPE patient on treatment with significant clinical improvement, even in the absence of conversion to seronegativity in either CSF or serum, on follow-up serological examination.

The prevention of an expected hepatic flare in HBe negative patients after lamivudine discontinuation.

The treatment with lamivudine leads to drug resistant mutations in 19 to 70% cases after 1- and 5-year therapy, respectively, associated with the risk of severe rebound of liver disease with alaninaminotransferase flare. In this situation, adefovir should be added, but this drug is not available in every country. We report three cases where we avoided the expected hepatic flare-ups by using IFN and isoprinosine. Based on this empirical experience, we suggest that the new drug has to be administered one month before discontinuation of lamivudine. Prospective trials are mandatory.