A Lyme borreliosis diagnosis probability score - no relation with antibiotic treatment response.

OBJECTIVES: (1) To describe epidemiological and clinical data of patients that present with the suspicion of Lyme borreliosis (LB); (2) to evaluate a previous published score that classifies patients on the probability of having LB, following-up patients' clinical outcome after antibiotherapy. METHODS: Inclusion criteria: patients with clinical manifestations compatible with LB and Borrelia (B.) burgdorferi positive serology, hospitalized in a Romanian hospital between January 2011 and October 2012. EXCLUSION CRITERIA: erythema migrans (EM) or suspicion of Lyme neuroborreliosis (LNB) with lumbar puncture performed for diagnosis. A questionnaire was completed for each patient regarding associated diseases, tick bites or EM history and clinical signs/symptoms at admission, end of treatment and 3 months later. Two-tier testing (TTT) used an ELISA followed by a Western Blot kit. The patients were classified in groups, using the LB probability score and were evaluated in a multidisciplinary team. Antibiotherapy followed guidelines' recommendations. RESULTS: Sixty-four patients were included, presenting diverse associated comorbidities. Fifty-seven patients presented positive TTT, seven presenting either ELISA or Western Blot test positive. No differences in outcome were found between the groups of patients classified as very probable, probable and little probable LB. Instead, a better post-treatment outcome was described in patients with positive TTT. CONCLUSION: The patients investigated for the suspicion of LB present diverse clinical manifestations and comorbidities that complicate differential diagnosis. The LB diagnosis probability score used in our patients did not correlate with the antibiotic treatment response, suggesting that the probability score does not bring any benefit in diagnosis.

Clinical and serological one-year follow-up of patients after the bite of Ixodes ricinus ticks infected with Borrelia burgdorferi sensu lato.

BACKGROUND: The risk of developing Lyme borreliosis (LB) after the bite of a Borrelia (B.) burgdorferi sensu lato (s.l.) infected tick in Romania is unknown. METHODS: The present prospective study, performed in 2010-2011 in a hospital in Romania, has followed-up clinical and serological outcome of patients that presented with B. burgdorferi positive Ixodes (I.) ricinus bite. A second group of patients, including age, sex and residence-matched individuals bitten by B. burgdorferi negative ticks, was followed-up as a control group. The subjects' outcome was evaluated one year after the tick bite. RESULTS: Forty-three out of 389 ticks detached from patients were positive by hbb Real-Time PCR (RT-PCR) for B. burgdorferi s.l. (mainly B. afzelii, but also B. garinii, B. burgdorferi sensu stricto, B. spielmanii/B. valaisiana and B. lusitaniae). Twenty patients bitten by B. burgdorferi positive ticks and twenty matched control patients returned for the one year follow-up. Two patients from the B. burgdorferi positive group developed clinical manifestations of acute LB (erythema migrans) and 5 patients seroconverted (two from the B. burgdorferi positive group and three from the B. burgdorferi negative group). Borrelia afzelii was identified in ticks collected from persons that developed erythema migrans (EM). Comparing the two groups of patients, no statistical significant differences were found regarding presence of clinical symptoms or seroconversion. CONCLUSIONS: No outcome differences were found between the group of patients bitten by B. burgdorferi positive ticks and the group of patients bitten by B. burgdorferi negative ticks.

Immunohistochemistry and real-time PCR as diagnostic tools for detection of Borrelia burgdorferi sensu lato in ticks collected from humans.

The objective of this study was to evaluate different methods used for detection of Borrelia burgdorferi sensu lato (s.l.) in ticks: immunohistochemistry followed by focus floating microscopy (FFM) and real-time polymerase chain reaction (real-time PCR) targeting the ospA and hbb genes. Additionally, an optimized ospA real-time PCR assay was developed with an integrated internal amplification control (IAC) for the detection of inhibition in the PCR assay and was validated as an improved screening tool for B. burgdorferi. One hundred and thirty-six ticks collected from humans in a hospital from Cluj-Napoca, Romania, were investigated regarding genus, stage of development and sex, and then tested by all three assays. A poor quality of agreement was found between FFM and each of the two real-time PCR assays, as assessed by concordance analysis (Cohen's kappa), whereas the agreement between the two real-time PCR assays was moderate. The present study argues for a low sensitivity of FFM and underlines that discordant results of different assays used for detection of B. burgdorferi in ticks are frequent.

Assesment of the Duke criteria for the diagnosis of infective endocarditis after twenty-years. An analysis of 241 cases.

BACKGROUND AND AIMS: In the absence of classical features (fever, cardiac murmur, and peripheral vascular stigmata) the diagnosis of infective endocarditis (IE) may be difficult. Current clinical guidelines for the diagnosis and management of IE recommend the use of modified Duke criteria. Correct and prompt diagnosis of IE is crucial for the treatment and outcome of the patients. The aim of this study was to evaluate the presence and the individual value of each criterion of the modified Duke criteria in our patients with infective endocarditis. METHODS: We performed a prospective observational study between January 2008 - June 2014, in which we enrolled consecutive adult patients admitted for suspicion of IE to the Hospital of Infectious Diseases and at the Heart Institute . We used and extensive database in order to collect demographic data, laboratory and echocardiography results, evolution and outcome of the patients. Using the modified Duke criteria we identified 3 categories of IE: definite, possible and rejected. In order to evaluate the importance of each criterion in the diagnosis of IE we tested two hypotheses. First, we excluded each criterion from the final diagnosis and we counted how many cases felt into a lower category. Second, after adding each major and minor criterion, we tested how many cases would have been classifiable as definite IE. RESULTS: The study included 241 adult patients with a mean age 58.16 years and sex ratio male/female 1.94. According to the modified Duke criteria 137 patients had definite IE, 79 patients had possible IE and 25 cases had rejected IE We had blood cultures positive IE in 109 cases and blood culture negative IE (BCNE) in 132 (71.21%) cases. Antibiotic treatment prior to blood culture was recorded in 152 (63.07%) patients. In the absence of the echocardiography major criterion, 43% of cases would become possible. After extraction of major microbiological criterion, only one third of definite cases would become possible. Minor criteria such as fever and predisposition contributed to the diagnosis only in 10% of cases. In the presence of vascular or immunological phenomena, or in the presence of minor microbiological criterion, half of the possible IE cases could become possible. CONCLUSION: Twenty-years after their launch, the Duke criteria for the diagnosis of IE continue to be important tools. Low index of suspicion of IE and inappropriate use of antibiotics may have a great negative impact on the diagnosis of IE. Nowadays, the scarcity of classical Osler manifestations - bacteremia, fever and peripheral stigmata - makes the diagnosis of IE a challenge.

Real-time PCR-based identification of Borrelia burgdorferi sensu lato species in ticks collected from humans in Romania.

The aims of our study were to determine (i) which tick species bite humans in Romania and (ii) the prevalence of Borrelia (B.) burgdorferi genospecies in these ticks. All ticks collected from patients who presented to the Clinic of Infectious Diseases Cluj Napoca in spring/summer 2010 were morphologically identified by an entomologist and tested for B. burgdorferi genospecies prevalence by a real-time PCR assay targeting the hbb gene and melting curve analysis. Out of 532 ticks, 518 were Ixodes ricinus, 10 Dermacentor marginatus, and 3 Haemaphysalis spp. ticks, and one unidentified tick due to destruction. Since evaluation of the hbb PCR revealed that it was not possible to differentiate between B. spielmanii/B. valaisiana and B. garinii/B. bavariensis, sequencing of an 800-bp fragment of the ospA gene was performed in these cases. Out of 389 investigated ticks, 43 were positive by hbb PCR for B. burgdorferi sensu lato. The positive samples were 42 Ixodes ricinus (11.1% B. burgdorferi sensu lato prevalence) and the one unidentified tick. Species identification revealed the presence of mainly B. afzelii, but also of B. garinii, B. burgdorferi sensu stricto, B. valaisiana, and B. lusitaniae. In 4 samples, differentiation between B. spielmanii/B. valaisiana was impossible. Our study shows that the most relevant human pathogenic B. burgdorferi genospecies - predominantly B. afzelii - are present in ticks collected from Romanian patients.

Markers of preclinical vascular disease and left ventricular diastolic dysfunction in patients with HIV infection.

BACKGROUND: HIV infected patients have an increased cardiovascular risk that may be linked not only to the infection itself but also to the metabolic side effects of the antiretroviral therapy. AIM: The aim of our study was to determine markers of aortic arterial stiffness, carotid intima-media thickness (IMT) and parameters of left ventricular diastolic function and to establish the relationship between these vascular and cardiac parameters in HIV infected patients. MATERIAL AND METHOD: In this cross sectional case control study 43 patients with HIV infection and 25 healthy controls, matched for age and sex were enrolled. Aortic pulse wave velocity (PWV) and augmentation index (AIx) using an oscillometric method were measured. Carotid IMT and left ventricular systolic and diastolic function were determined by ultrasonography. Clinical status, laboratory parameters (glucose and lipid metabolism), and markers of disease activity were also recorded. RESULTS: In patients with HIV infection PWV was increased when compared to controls (p=0.02), but there were not significant differences in carotid IMT (p= 0.17). There were no differences for classical risk factors between HIV infected patients and controls with the exception of triglycerides level (p<0.001). HIV infected patients had a significant reduction in E/A ratio when compared to controls (p= 0.03). Significant differences were found for age (p=0.001), PWV (0.002) and carotid IMT (p=0.02) between patients with and without left ventricular diastolic dysfunction (LVDD). In multiple regression analyze only PWV remained correlated with LVDD (OR = 2.90, 95%CI: 1.41-5.97, p=0.004). CONCLUSIONS: In patients with HIV infection, without overt cardiovascular disease, arterial stiffness was increased. This finding is correlated with markers of LVDD. Increased arterial stiffness may be one of the mechanisms implicated in the alteration of left ventricular diastolic function in HIV infected patients.

Arterial stiffness and carotid intima-media thickness in HIV infected patients.

BACKGROUND: Cardiovascular disease is an increasing cause of morbidity and mortality in HIV-infected patients. The increased cardiovascular risk is linked to traditional risk factors for atherosclerosis but also, to HIV infection itself which can damage the arterial wall and the antiretroviral therapy (ART) implicated in metabolic disturbances. The aim of our study was to identify the effects of HIV and ART on carotid artery intima-media thickness (C-IMT) and on arterial stiffness, parameters which are used for the evaluation of cardiovascular risk. PATIENTS AND METHODS: A cross-sectional case-control study of 63 HIV-infected patients (56 exposed to ART, 7 ART naive) and 36 controls matched for age and sex was performed. C-IMT, and arterial stiffness were measured ultrasonographically using an ALOKA ProSound α 10 echo-device. Parameters of arterial stiffness were measured at the common carotid and brachial arteries. RESULTS: HIV-infected patients had a greater C-IMT than controls (p<0.01). There were significant differences regarding arterial stiffness parameters in HIV infected patients compared to controls, and between the groups of patients with different types of ART, especially at the level of carotid artery. Patients with HIV infection had reduced carotid compliance compared to controls (p<0.01). Patients exposed to reverse transcriptase inhibitort (RTI), had increased ß stiffness index (p=0.01) and carotid PWV (p=0.02) and reduced carotid compliance (p<0.01) compared to controls. CONCLUSIONS: HIV infection and ARV treatment is associated with increased C-IMT, and an increase in the arterial stiffness of the large arteries. These vascular modifications are possible causes of increased cardiovascular risk observed in HIV infected patients.

Multiplex cytokine profiling in patients with sepsis.

A major goal for the clinical research in sepsis is mapping the various mediators driving the systemic manifestations of infection. Identifying relevant mediators responsible for the physiological alterations during sepsis may offer diagnostic and therapeutic opportunities. We aimed to explore the novel approach of simultaneously measuring several biomolecules using the multiplex technique and to study its relevance in diagnosing and monitoring septic patients. In 30 patients fulfilling American College of Chest Physicians and the Society of Critical Care Medicine sepsis criteria, we simultaneously measured 17 cytokines during the first 7 days after admission. We analysed the results with respect to the presence of septic shock and survival. Five patients died during the study. We found a significant positive correlation between the monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1ß and interleukin (IL)-8 levels in the first 3 days and Sepsis-related Organ Failure Assessment score on day 1. Most cytokines showed no significant difference between patients with mild or severe sepsis. The initial levels of MIP-1ß and granulocyte macrophage colony-stimulating factor were lower in patients with septic shock than in patients without shock. IL-8 and MCP-1 early after admission were higher in the non-survivors (p < 0.05). In the multivariate logistical regression, the initial levels of IL-8 were the most predictive for fatal outcome. Moreover, IL-1ß, IL-6, IL-8, IL-12, interferon-γ, granulocyte colony-stimulating factor and tumour necrosis factor-α exhibited persistent increases in non-survivors. The simultaneous evaluation of multiple cytokines in sepsis may identify complex cytokine patterns that reflect the systemic response associated with shock and mortality.