Clinical Perspective on Human Immunodeficiency Virus Care of Ukrainian War Refugees in Poland.

BACKGROUND: The Russian invasion of Ukraine forced migration for safety, protection, and assistance. Poland is the primary sheltering country for Ukrainian refugees, providing support including medical care, which resulted in the rapid ∼15% increase in the number of followed-up people with human immunodeficiency virus (HIV) (PWH) in the country. Here, we present the national experience on HIV care provided for refugees from Ukraine. METHODS: Clinical, antiretroviral, immunological, and virologic data from 955 Ukrainian PWH entering care in Poland since February 2022 were analyzed. The dataset included both antiretroviral-treated (n = 851) and newly diagnosed (n = 104) patients. In 76 cases, protease/reverse transcriptase/integrase sequencing was performed to identify drug resistance and subtype. RESULTS: Most (70.05%) of the patients were female, with a predominance of heterosexual (70.3%) transmissions. Anti-hepatitis C antibody and hepatitis B antigen were present in 28.7% and 2.9% of the patients, respectively. A history of tuberculosis was reported in 10.1% of cases. Among previously treated patients, the viral suppression rate was 89.6%; 77.3% of newly HIV diagnosed cases were diagnosed late (with lymphocyte CD4 count <350 cells/µL or AIDS). The A6 variant was observed in 89.0% of sequences. Transmitted mutations in the reverse transcriptase were found in 15.4% treatment-naive cases. Two patients with treatment failure exhibited multiclass drug resistance. CONCLUSIONS: Migration from Ukraine influences the characteristics of HIV epidemics in Europe, with an increase in the proportion of women and hepatitis C coinfected patients. Antiretroviral treatment efficacy among previously treated refugees was high, with new HIV cases frequently diagnosed late. The A6 subtype was the most common variant.

Non-HIV-related comorbidities and uncontrolled HIV replication are independent factors increasing the odds of hospitalization due to COVID-19 among HIV-positive patients in Poland.

PURPOSE: Immunocompromised patients are postulated to be at elevated risk of unfavorable outcomes of COVID-19. The exact effect of HIV infection on the course of COVID-19 remains to be elucidated. The aim of the study was to describe the epidemiological and clinical aspects of SARS-CoV-2 infection in HIV-infected individuals. METHODS: The HIV-positive patients who were diagnosed with SARS-CoV-2 infection were identified through thirteen specialist HIV clinics routinely following them due to HIV treatment. The data were collected between November 2020 and May 2021 through an on-line electronical case report form (SurveyMonkey®). The collected information included demographics, lifestyle, comorbidities, HIV care history, COVID-19 clinical course and treatment. Logistic regression models were used to identify factors associated with the odds of death or hospitalization due to COVID-19. RESULTS: One hundred and seventy-three patients with HIV-SARS-CoV-2 coinfection were included in the analysis. One hundred and sixty-one (93.1%) subjects had a symptomatic course of the disease. Thirty-nine (23.1%) of them were hospitalized, 23 (13.3%) necessitated oxygen therapy. Three (1.8%) patients required admission to the intensive care unit and 6 (3.5%) patients died. The presence of comorbidities and an HIV viral load of more than 50 copies/mL were linked to the increased odds of hospitalization (OR 3.24 [95% CI 1.27-8.28]) and OR 5.12 [95% CI 1.35-19.6], respectively). CONCLUSIONS: As depicted by our analyses, HIV-positive patients with comorbidities and/or uncontrolled HIV replication who are diagnosed with SARS-CoV-2 infection should be considered of high risk of poor COVID-19 outcome and followed up carefully.

Preliminary report on the provision of HIV care to war refugees with HIV who are migrating from Ukraine: data from the ECEE Network Group.

The ECEE Network Group investigated early provision of HIV care to war refugees migrating from Ukraine in Central and Eastern Europe (CEE) through an online survey. Fourteen countries admitting war refugees from Ukraine on March 31, 2022, completed the survey. Most centers (86%) organized provision of same day antiretroviral therapy (ART) for at least 30 days (77%), but indicated that it may affect the local HIV care. CEE countries put effective emergency mechanisms, which need continuation with international support.

Molecular epidemiology and HIV-1 variant evolution in Poland between 2015 and 2019.

The occurrence of HIV-1 subtypes differs worldwide and within Europe, with non-B variants mainly found across different exposure groups. In this study, we investigated the distribution and temporal trends in HIV-1 subtype variability across Poland between 2015 and 2019. Sequences of the pol gene fragment from 2518 individuals were used for the analysis of subtype prevalence. Subtype B was dominant (n = 2163, 85.90%). The proportion of subtype B-infected individuals decreased significantly, from 89.3% in 2015 to 80.3% in 2019. This was related to the increasing number of subtype A infections. In 355 (14.10%) sequences, non-B variants were identified. In 65 (2.58%) samples, recombinant forms (RFs) were noted. Unique recombinant forms (URFs) were found in 30 (1.19%) sequences. Three A/B recombinant clusters were identified of which two were A6/B mosaic viruses not previously described. Non-B clades were significantly more common among females (n = 81, 22.8%, p = 0.001) and heterosexually infected individuals (n = 45, 32.4%, p = 0.0031). The predominance of subtype B is evident, but the variability of HIV-1 in Poland is notable. Almost half of RFs (n = 65, 2.58%) was comprised of URFs (n = 30, 1.19%); thus those forms were common in the analyzed population. Hence, molecular surveillance of identified variants ensures recognition of HIV-1 evolution in Poland.

Low prevalence of doravirine-associated resistance mutations among polish human immunodeficiency-1 (HIV-1)-infected patients.

INTRODUCTION: Doravirine (DOR) is a novel non-nucleoside reverse transcriptase inhibitor (NNRTI) that retains activity against common NNRTI resistance mutations. In this study, we aimed to investigate the prevalence of DOR resistance mutations compared with that of resistance mutations for other NNRTIs among HIV-1-infected treatment-experienced and -naïve patients from Poland. METHODS: Resistance to DOR and other NNRTIs was assessed in two datasets: 1760 antiretroviral treatment-naïve HIV-1 patients and 200 treatment-experienced patients. All 1960 sequences were derived from the patients using bulk sequencing. For resistance analyses, Stanford HIV drug resistance database scores were used. RESULTS: Overall, DOR resistance was present in 32 patients (1.62%), of whom 13 (0.74%) were naïve and 19 (9.50%) were treatment-experienced. The most common DOR resistance mutations observed among the naïve patients were A98G and K101E (0.2% each), and those among cART-experienced patients were L100I (2.0%), K101E, V108I, H221Y, and P225H (1.5% each). Furthermore, among the naïve patients, less common resistance to DOR (0.7%) compared with that to nevirapine (NVP) (2.1%; p = 0.0013) and rilpivirine (5.40%; p < 0.0001) was observed. For sequences obtained from treatment-experienced patients, the frequency of resistance to DOR (9.5%) was lower than that for efavirenz (25.5%; p < 0.0001) and NVP (26.0%; p < 0.0001). CONCLUSIONS: The frequency of transmitted drug resistance to DOR is low, allowing for effective treatment of antiretroviral treatment-naïve patients and rapid treatment initiation. In cART-experienced patients, this agent remains an attractive NNRTI option with a higher genetic barrier to resistance.

Dermoscopic Features of Giant Molluscum Contagiosum in a Patient with Acquired Immunodeficiency Syndrome.

Giant molluscum contagiosum (MC) is a peculiar variant of the disease with the presence of multiple or single lesions larger than 5 mm. In contrast to typical molluscum contagiosum, dermoscopic features of giant lesions have been poorly described, and none of the reports included multiple giant lesions in an immunocompromised patient. We present a patient with acquired immunodeficiency syndrome diagnosed with multiple giant molluscum contagiosum along with the dermoscopic features of this entity. We examined a 40-year-old patient who had been diagnosed with acquired immunodeficiency syndrome (AIDS) two months earlier. The disease defining AIDS was cerebral toxoplasmosis (initially presenting as a brain tumor several months earlier). Laboratory investigation showed a decreased CD4 cell count of 11 cells/mm3 and HIV viral load of 252 472 copies/mL. The patient was referred to the Department of Dermatology due to multiple flesh-colored, asymptomatic nodules with superficial telangiectasia that had been observed on the face for several weeks (Figure 1, a). Dermoscopy of larger (>5 mm) skin lesions showed yellowish globules of different size and random distribution, separated by smaller, oval-shape white globules and polymorphic vessels (Figure 1, b-d). Dermoscopy of smaller skin lesions showed the presence of a central yellow globule and white structureless area with irregular linear vessels of radial arrangement at the periphery (Figure 1, e). Histopathological examination confirmed the diagnosis of molluscum contagiosum (MC); special staining showed the details of the lesion (Figure 2, a-c). Antiretroviral therapy with Triumeq® (dolutegravir + abacavir + lamivudine) was initiated. After discussing MC treatment options with the patient, we decided to delay the treatment and wait for the effect of antiretroviral therapy. Partial regression of MC lesions was observed after 5 months; laboratory investigations showed a CD4 cell count of 99 cells/mm3 and a HIV viral load of 56 copies/mL. Along with continuation of antiretroviral therapy, the patient received treatment with topical imiquimod (Aldara®) for 12 weeks. Subsequently, a few lesions resistant to previous treatment were treated with cryosurgery and the patient was instructed to apply imiquimod only to new-onset/regrowing lesions. Clinical evaluation after 2 months revealed a good clinical and aesthetic effect (Figure 3). MC is a viral disease caused by a DNA virus of the Poxviridae family (MCV-1 or MCV-2). The infection most commonly affects children and sexually active adults, and may be diagnosed based on physical examination in the majority of cases. Typical clinical presentation includes single to multiple, 2-5 mm, flesh-colored, asymptomatic nodules with central umbilication. Dermoscopy is a non-invasive diagnostic method that allows skin examination with magnification, therefore improving the accuracy of dermatological diagnosis. It was primarily developed to detect melanoma, but in recent years the role of this method in general dermatology has been constantly increasing. There have been several published reports that demonstrated the utility of dermoscopy in the diagnosis of MC. Most commonly observed structures include a central orifice and blood vessels arranged in punctiform, radial or mixed flower pattern (1). Giant molluscum contagiosum is an atypical variant of the disease, with the presence of multiple or single lesions larger than 5 mm (2). The diagnosis of giant MC usually indicates immunodeficiency and has been mainly described in HIV-positive patients, but also in coexistence with leukemia, sarcoidosis, Wiskott-Aldrich syndrome, selective immunoglobulin M deficiency, atopic dermatitis, and after splenectomy, bone marrow transplantation, and during immunosuppressive therapy (3). Giant MC may mimic other benign or malignant dermatoses, and the final diagnosis is usually based on histopathological examination. The list of differential diagnoses is long and includes basal cell carcinoma, keratoacanthoma, viral wart, varicella, intradermal nevi, pyogenic granuloma, lichen planus, atypical mycobacterial infection, pneumocystosis, cutaneous cryptococcosis, and histoplasmosis (3). In contrast to typical MC, dermoscopic features of giant MC have been poorly described, and none of the reports included multiple lesions in immunocompromised patient. Mun et al. described a pattern of multiple shiny white clods in giant MC observed in a 2-year-old girl in the perianal area (4). A different dermoscopic image - with prominent arborizing vessels and polylobular white structureless areas - was reported by Uzuncakmak et al., who described giant MC on the eyelid in a 25-year-old woman (2). Similar dermoscopic features of atypical MC (5 mm in size) were described by Zaballos et. al. (5). The course and treatment of MC differ in immunocompetent and in immunocompromised individuals. While the infection is usually mild and self-limiting in the former group, in the latter it may be extensive, symptomatic, and resistant to therapy. Treatment methods commonly applied in immunocompetent patients such as cryotherapy, curettage, and electrocautery are not generally recommended in patients with severe immunodeficiency as they pose a risk of secondary infection or autoinoculation (6). Additionally, such treatment of multiple lesions is connected with pain and higher risk of postinflammatory changes/scarring (7). According to the literature, treatment with local immunomodulators - including imiquimod cream, interferon-a (IFN-a) injections and cidofovir - appears to be effective (6). Topical 5% imiquimod was most commonly used, and although not licensed for this indication it was shown to be effective in HIV-positive individuals, including treatment of giant MC lesions (7). Regardless of the topical treatment, previous reports documented a correlation between immunity status and the extension of MC lesions. Therefore, effective antiretroviral therapy may itself lead to resolution of MC [8]. To sum up, the presented report introduced additional observations into the dermoscopic spectrum of giant MC. The observed dermoscopically large yellowish globules seem to correspond with the crypts and the surrounding white structures with the areas of lobulated, endophytic epidermal hyperplasia. The presence of vascular structures in dermoscopy corresponds with the blood vessels tightly surrounding inverted hyperplastic epidermal lobules (Figure 2, b). Dermoscopic features od giant MC are different than those observed in small lesions. Interestingly, the dermoscopic appearance of smaller lesions observed in our patient seemed to be similar to MC eruptions described in immunocompetent patients (1). In case of clinical suspicion giant MC coexisting with smaller lesions, dermoscopic assessment of the latter may serve as a clue to diagnosis.

Streptococcus suis Meningitis: Epidemiology, Clinical Presentation and Treatment.

Streptococcus suis, a prevalent porcine pathogen, may sporadically cause infections in humans, and has recently emerged as a cause of zoonoses in some professionals. The aim of this article was to review available data on epidemiology, etiopathogenesis, diagnostics, and management of the most common form of S. suis infection, purulent meningitis. Literature data show that S. suis is an important etiological factor of purulent meningitis, especially in subjects being occupationally exposed to contact with pigs and/or pork meat. Owing to growing incidence of S. suis meningitis, a history of such exposure should be verified in each patient presenting with typical meningeal symptoms. Whenever S. suis was confirmed as the etiological factor of purulent meningitis, therapeutic protocol should be adjusted appropriately, to avoid patient's exposure to potentially ototoxic antimicrobial agents and corticosteroids. Considering the biphasic character of S. suis meningitis and its frequently atypical outcome, all individuals with this condition should be optimally supervised by a multidisciplinary team, including an ENT specialist.

HIV encephalitis in a patient on antiretroviral therapy: a case report.

We present the case of a 52-year-old man with human immunodeficiency virus (HIV) encephalitis resulting from cerebrospinal fluid (CSF) viral escape, to illustrate therapeutic challenges in patients with emergent CSF genotypic HIV drug resistance. This case report highlights the usefulness of CSF HIV-resistance testing to guide antiretroviral therapy and treatment optimizing decisions.

Predictors for diagnosis of tick-borne encephalitis infection in Poland, 2009-2010.

BACKGROUND: Tick-borne encephalitis (TBE) is a viral infection with no available treatment. Due to its non-specific symptoms, TBE tends to be under-diagnosed and under-reported. We aimed to identify factors predicting TBE diagnosis to develop a diagnostic algorithm for use by physicians. METHODS: We conducted a case-control study using data routinely collected in Poland during 2009-2010. We included patients admitted to hospitals, who were assigned an International Classification of Disease (ICD) code indicating aseptic meningo-encephalitis. Cases were confirmed by detection of specific IgG and IgM antibodies. Patients that tested negative for TBE were included as controls. We used logistic regression to determine associations and recursive partitioning to build a diagnostic algorithm based on 70% of the dataset, and validated the algorithm using the remaining 30%. RESULTS: Of 774 patients, 273 (35%) were TBE-positive. Cerebrospinal fluid protein levels and presence of a tick bite were key decision points in the algorithm, while living in a TBE endemic area was not important. Application of the algorithm to the validation dataset yielded a sensitivity of 89% and specificity of 37%. CONCLUSIONS: TBE should be included in routine diagnostic protocols for all cases admitted to hospitals with meningitis or encephalitis. However, in resource-limited settings and in regions with unknown TBE endemicity status, our algorithm could indicate which cases should be tested for TBE.

Transmitted HIV drug resistance in antiretroviral-treatment-naive patients from Poland differs by transmission category and subtype.

OBJECTIVES: The surveillance of HIV-transmitted drug resistance mutations (t-DRMs), including temporal trends across subtypes and exposure groups, remains a priority in the current management of the epidemic worldwide. METHODS: A cross-sectional analysis of 833 treatment-naive patients from 9 of 17 Polish HIV treatment centres. Partial pol sequences were used to analyse drug resistance with a general time reversible (GTR)-based maximum likelihood algorithm used for cluster/pair identification. Mutation frequencies and temporal trends were investigated. RESULTS: t-DRMs were observed in 9% of cases (5.8% for NRTI, 1.2% NNRTI and 2.0% PI mutations) and were more common among heterosexually infected (HET) individuals (13.4%) compared with MSM (8.3%, P = 0.03) or injection drug users (IDUs; 2.9%, P = 0.001) and in MSM compared with IDUs (P = 0.046). t-DRMs were more frequent in cases infected with the non-B variant (21.6%) compared with subtype B (6.6%, P < 0.001). With subtype B a higher mutation frequency was found in MSM compared with non-MSM cases (8.3% versus 1.8% for IDU + HET, P = 0.038), while non-B variants were associated with heterosexual exposure (30.4% for HET versus 4.8% for MSM, P = 0.019; versus 0 for IDU, P = 0.016). Trends in t-DRM frequencies were stable over time except for a decrease in NNRTI t-DRMs among MSM (P = 0.0662) and an NRTI t-DRM decrease in HET individuals (P = 0.077). With subtype B a higher frequency of sequence pairs/clusters in MSM (50.4%) was found compared with HET (P < 0.001) and IDUs (P = 0.015). CONCLUSIONS: Despite stable trends over time, patterns of t-DRMs differed notably between transmission categories and subtypes: subtype B was associated with MSM transmission and clustering while in non-B clades t-DRMs were more common and were associated with heterosexual infections.

Time trends in HIV-1 transmitted drug resistance mutation frequency in Poland.

INTRODUCTION: In Poland, the HIV epidemic has shifted recently from being predominantly related to injection drug use (IDU) to being driven by transmissions among men-who-have-sex-with-men (MSM). The number of new HIV cases has increased in the recent years, while no current data on the transmitted drug resistance associated mutations (tDRM) frequency trend over time are available from 2010. In this study, we analyze the temporal trends in the spread of tDRM from 2008 to 2013. MATERIALS AND METHODS: Partial pol sequences from 833 antiretroviral treatment-naive individuals of European descent (Polish origin) linked to care in 9 of 17 Polish HIV treatment centres were analyzed. Drug resistance interpretation was performed according to WHO surveillance recommendations, subtyping with REGA genotyping 2.0 tool. Time trends were examined for the frequency of t-DRM across subtypes and transmission groups using logistic regression (R statistical platform, v. 3.1.0). RESULTS: Frequency of tDRM proved stable over time, with mutation frequency change from 11.3% in 2008 to 8.3% in 2013 [OR: 0.91 (95% CI 0.80-1,05), p=0.202] (Figure 1a). Also, no significant differences over time were noted for the subtype B (decrease from 8.4% 2008 to 6.2% in 2013 [OR: 0.94 (95% CI 0.79-1.11), p=0.45] and across non-B variants [change from 22.6% 2008 to 23.1% in 2013, OR: 0.94 (95% CI 0.75-1.19), p=0.62]. When patient groups were stratified according to transmission route, in MSM there was a trend for a NNRTI t-DRM decrease (from 6.8% 2008 to 1% in 2013, OR: 0.61 (95% CI 0.34-1.02), p=0.0655, slope -0.74%/year) (Figure 1b), related to the subtype B infected MSM (decrease from 7% 2008 to 1% in 2013, OR: 0.61 (95% CI 0.34-1.03), p=0.0662, slope -0.75%/year). Overall tDRM frequency decrease was also noted for the heterosexually infected patients [from 17.6% 2008 to 10.3% in 2013, OR: 0.83 (95% CI 0.67-1.02, p=0.077, slope -2.041%/year)] but did not associate with drug class (Figure 1c). In IDUs, the trends in t-DRM frequency were not significant over time (change from 1.9% in 2008 to 0 in 2013 [OR:1.24 (95% CI 0.73-2.26), p=0.4)]. CONCLUSIONS: The frequency of t-DRM in Poland is generally stable over time. Decrease in the overall tDRM frequency in heterosexual infected cases and NNRTI resistance in subtype B infected MSM may be related to the higher treatment efficacy of current cART.

New endemic foci of tick-borne encephalitis (TBE) identified in districts where testing for TBE was not available before 2009 in Poland.

BACKGROUND: Tick-borne encephalitis (TBE) is found in limited endemic foci in Poland. Lack of diagnosis limits disease detection in non-endemic provinces. METHODS: In 2009, we enhanced TBE surveillance to confirm the location of endemic foci and inform vaccination policy. In 105 hospitals located in 11/16 provinces, we identified suspected TBE cases through admission ICD-10 codes indicating aseptic meningo-encephalitis or from specimens tested for TBE. The National Reference Laboratory confirmed cases at no cost, by testing serum and/or cerebrospinal fluid using ELISA method. We calculated TBE reported rates as the number of confirmed TBE cases per 100,000 inhabitants. Adjusting to neighbouring districts, we classified districts as non-endemic (<0.1 cases per 100,000 inhabitants), low endemic (> = 0.1 to <1), moderately endemic (> = 1 to <5) and highly endemic (> = 5). We compared surveillance data obtained in 2009 with 2004-2008 baseline data. RESULTS: Among 166,099 admissions, we identified 1,585 suspected TBE cases of which 256 were confirmed. Physicians reported more suspected cases among patients <40 years old (12 cases per 1,000 admissions) than among older patients (8 cases per 1,000 admissions). However, patients <40 years of age were confirmed less frequently (16%), than older patients (35%). Physicians reported more suspected cases in districts classed as endemic during 2004-2008 (12 cases per 1,000 admissions, 77% tested for TBE) than in districts classed as non-endemic (7 cases per 1,000 admissions, 59% tested). Of the 38 newly identified endemic districts, 31 were adjacent to 2004-2008 endemic districts and 7 were isolated. CONCLUSIONS: Enhanced surveillance detected 38 new endemic districts to be considered for TBE vaccination. However, lack of consistent testing in districts believed to be TBE-free remained an obstacle for mapping TBE risk. Although the disease affects mostly older adults and the elderly, more attention is given to the diagnosis of TBE in young patients. Solutions need to be identified to sustain sensitive, acceptable and affordable TBE surveillance in all districts of Poland. Also, higher attention should be given to the diagnosis of TBE in the elderly.

[Relationship between inflammatory changes revealed in cerebrospinal fluid and prognosis in acute viral encephalitis]. / Zaleznosc pomiedzy wystepowaniem zmian zapalnych w plynie mózgowo-rdzeniowym a rokowaniem w ostrym wirusowym zapaleniu mózgu.

OBJECTIVE: To assess the relationship between inflammatory changes in cerebrospinal fluid (CSF) and prognosis in patients with acute viral encephalitis (AVE). PATIENTS AND METHODS: retrospective medical records analysis of 99 cases of AVE, 37 females and 62 males, age 4-71. Patients were assigned to 2 subgroups: group I--without inflammatory changes in CSF (cytosis < or = 10/mm3 - 40 cases) and group II--with detectable abnormalities in CSF (cytosis >10/mm3 - 59 cases). Long term prognosis and unfavorable outcome were assessed at the moment of discharge from hospital and with a use of questionnaire sent to patients and were described as: 0--complete recovery, 1--long-term disabilities, 2--death. MAIN OBSERVATIONS: Among 99 patients with acute viral encephalitis complete recovery was observed in 61% of cases, in 32% the disease resulted in long term consequences and disabilities and 7% died from reasons related to encephalitis. RESULTS: Patients without inflammatory changes in CSF statistically significantly (p < 0.05) more frequently suffered from coma, early epileptic episodes, respiratory disorders, unfavorable outcome and epilepsy. In a group II statistically significantly more often fever and Herpes simplex etiology were observed. CONCLUSIONS: (1) Among 99 patients in 32% AVE resulted in long-term (subtle as well as severe) disabilities and 7% died from reasons related to AVE. (2) Patients without inflammatory abnormalities in CSF tended to have more severe clinical course and worse prognosis than those with detectable increase of CSF cytosis (>10 cells/mm3).

Coagulation, coma, and outcome in bacterial meningitis--an observational study of 38 adult cases.

OBJECTIVES: The purpose of this study was to evaluate the epidemiology of intravascular coagulation in bacterial meningitis and to recognise the associations with disease severity and outcome. METHODS: Thirty-eight consecutively admitted adult patients with microbiologically proven bacterial meningitis were observed prospectively for platelets count (PLT), platelets-decline (dPLT), prothrombin ratio (PTr), INR, and D-dimer levels during the first three days in relation to disease severity (Glasgow Coma Scale--GCS, APACHE-III) and outcome (Glasgow Outcome Scale--GOS). RESULTS: The prevalence of activated coagulation measured by abnormal laboratory results varied respectively: PTr--30%, INR--36%, PLT--38%, dPLT--50%, and D-dimer--88%. Patients with GCS <9 at admission presented with laboratory results suggesting triggered coagulation: dPLT 48 vs. 15%/day (p=0.0246), INR 1.6 vs. 1.12 (p=0.0014), PTr 76 vs. 93% (p=0.0020). An unfavourable outcome (GOS 1-4) was observed in 42% of patients and was associated with: PLT <170 or >265 G/L (OR--24.4; p=0.0006), PTr <82% (OR--5.00; p=0.0388), INR >1.1 (OR--5.04; 0.0336), and D-dimer >850 ng/ml (OR--24.0; p=0.0033). CONCLUSIONS: Coagulation was activated in a majority of patients with bacterial meningitis and related to coma and unfavourable outcome.

[Occurrence of disseminated intravascular coagulation in purulent meningitis and influence on mortality in 118 patients]. / Wystepowanie wykrzepiania sródnaczyniowego w ropnym zapaleniu opon mózgowo-rdzeniowych i wplyw na smiertelnosc u 118 pacjentów.

UNLABELLED: Disseminated intravascular coagulation (DIC) is an important, but not satisfactory explained risk factor of death in purulent meningitis (PM). OBJECTIVE: Evaluation of: 1) acute thrombocytopenia (ATP) in patients with PM, 2) dynamics in changes of peripheral blood platelet (PLT) count and serum coagulation factors, 3) correlation between acute DIC and mortality in PM. METHODS: Analysis ofATP (platelets < or = 150 K/microL and/or decrease in PLT > or = 100 K/microL/24 hours) and prothrombin ratio, fibrinogen, d-dimmer and antithrombin III in survivors and nonsurvivors in 118 adult patients with PM. 37 further patients have been disclosed because of non-bacterial PM or chronic conditions predisposing to ATP or DIC. MAIN OBSERVATIONS: DIC defined as ATP occurred in 56 %, defined as elevated d-dimmer level in 72%. 16 (14%) patients died. RESULTS: Mortality correlated significantly with the lowest PLT count on first 3. days (p=0,049) and with PLT decline (p=0,015). Differences in survivors/nonsurvivors were observed in: ATP on 1. day 48% vs. 75% (p<0,05), daily PLT decline 9%/day vs. 32%/day (p<0,05), prothrombin ratio 89% vs. 74% (p<0,05) and INR 1,2 vs. 1,7 (p<0,005). CONCLUSION: DIC is an important risk factor in PM. Aggravated DIC do correlate significantly with higher risk of death.

Prolonged dysphagia due to Listeria-rhombencephalitis with brainstem abscess and acute polyradiculoneuritis.

We report a case of previously healthy student with acute rhombencephalitis and brainstem abscess caused by Listeria monocytogenes. The disease begun with uncharacteristic prodromal symptoms of gastrointestinal infection followed by headache and vertigo. After hospital admission the patient rapidly deteriorated, presenting pronounced dysphagia and respiratory failure requiring mechanical ventilation. The diagnosis was established upon clinical symptoms of infection, brainstem involvement, typical MRI findings and positive for L. monocytogenes blood culture. Infection was complicated by acute, demyelinating neuropathy, diagnosed upon clinical symptoms of frail palsy confirmed by ENG. Initially introduced empirical doxycyclin/ceftriaxon treatment was subsequently changed to targeted ampicillin/gentamycin therapy, mechanical ventilation, intravenous human immunoglobulin treatment, tracheostomy and endoscopic gastrostomy. Prolonged dysphagia resolved after rehabilitation. After one year the patient remains well with only slight dysmetria.