Proton Chemical Shift Imaging Study of the Combined Antiretroviral Therapy Impact on Neurometabolic Parameters in Chronic HIV Infection.

BACKGROUND AND PURPOSE: The introduction of combination antiretroviral therapy has failed to reduce the high prevalence of mild forms of HIV-associated neurocognitive disorders. The aim of this study was to test the effect of combined antiretroviral therapy on brain metabolite ratios in chronic HIV infection by using proton chemical shift imaging. MATERIALS AND METHODS: We performed 2D chemical shift imaging in 91 subjects (31 HIV+ patients with chronic infection on combination antiretroviral therapy, 19 combination antiretroviral therapy-naïve HIV+ subjects with chronic infection, and 41 healthy controls), covering frontal and parietal subcortical white and cingulate gyrus gray matter, analyzing ratios of NAA/Cr and Cho/Cr on long-TE and mIns/Cr on short-TE MR spectroscopy. We correlated neurometabolic parameters with immunologic, clinical, data and combined antiretroviral therapy efficacy scores. RESULTS: There was a significant decrease in NAA/Cr (P < .05) in HIV-positive patients on and without combined antiretroviral therapy, compared with healthy controls in all locations. There were significant differences in Cho/Cr (P < .05) and mIns/Cr (P < .05) ratios between HIV+ patients on and without therapy, compared with healthy controls, but these differed in distribution. There were no significant differences in brain metabolite ratios between the 2 groups of chronically HIV-infected patients. The CNS penetration efficacy score showed weak positive correlations only with Cho/Cr ratios in some locations. CONCLUSIONS: The impact of combined antiretroviral therapy on the process of neuronal loss and dysfunction in chronic HIV infection appears to be suboptimal in successful peripheral suppression of viral replication. Spectroscopic imaging might be a useful tool for monitoring the effects of different combined antiretroviral therapy regimens on brain metabolite ratios.

Treatment of Periodontal Disease with an Octenidine-based Antiseptic in HIV-positive Patients.

OBJECTIVE: To evaluate the effects of a periodontal therapy with subsequent application of an octenidine (OCT)-based antiseptic in HIV-positive patients receiving highly active antiretroviral therapy. METHODS: HIV-positive patients with a clinically diagnosed periodontal disease were randomly divided into two groups (n = 30/group). Both groups initially received a periodontal therapy. Patients in the OCT group additionally used an OCT-based mouthwash. Subgingival plaque samples and periodontal indices were analysed prior to treatment onset as well as one and 3 months post-treatment. RESULTS: Periodontal therapy has resulted in a significant decrease in the values of all periodontal indices one and 3 months following the therapy completion (P = 0.000). The effects of the two applied therapeutic protocols differed significantly in terms of the variation in the PBI (F = 4.617; P = 0.017) and the PD (F = 3.203; P = 0.044) value. In the patients in the OCT group, a more pronounced decrease in the PBI and PD was noted at 1-month follow-up as well as a greater increase in the PD value 3 months upon treatment completion. In the OCT group, no more atypical microorganisms were detectable 1 month post-treatment, while in the control group they were found in 34.5% of patients. CONCLUSIONS: The periodontal therapy bears good results in HIV-positive patients. Additional administration of OCT contributes to the significant decline in the PBI and DS values and eliminates atypical microorganisms within 1 month post-treatment. However, more favourable results were not noted in the OCT group at the 3-month assessment.

Nutritional profile of adult patients with celiac disease.

Celiac disease (CD) is a chronic immune-mediated gluten dependent enteropathy induced by ingestion of gluten, characterized by intestinal malabsorption and subtotals or total atrophy of intestinal villi. The predominant consequence of CD in untreated patients, is malnutrition as a result of malabsorption. Moreover, several and increasing extra-intestinal clinical manifestations have been described in the CD patients. Strict adherence to a gluten-free diet (GFD) improves nutritional status, inducing an increase in fat and bone compartments, but does not completely normalize body composition and nutritional deficiencies. An early and accurate evaluation of nutritional status can be of the pivotal step in the clinical management of the adult CD patients. The aim of this review is to present the most important and recent data on nutritional and metabolic features in the CD adult patients, the related implications and the effects of the GFD on these conditions.

Extensive myelitis after oral polio vaccination: MRI features.

A 7-year-old boy presented with fever and ataxia 20 days after oral polio vaccination. Magnetic resonance imaging showed extensive myelitis, involving both anterior and posterior horns of the gray matter. Complete posttreatment recovery was evident. Postvaccinal myelitis after oral polio vaccination, of either infectious or immune mediated etiology, is very rare entity that should be promptly recognized in order to initiate adequate treatment.

Ongoing outbreak of aseptic meningitis associated with echovirus type 30 in the City of Novi Sad, Autonomous Province of Vojvodina, Serbia, June - July 2010.

Since June 2010, incidence of aseptic meningitis has increased in Novi Sad, Autonomous Province of Vojvodina, Serbia. From 2 June to 25 July 2010, 80 cases of aseptic meningitis were notified, with an incidence rate ranging from 10 to 366 per 100,000 population in different local communities. The majority of cases (n=64) were aged between two and 15 years. Echovirus 30 was cultured from two of four cerebrospinal fluid specimens. The outbreak, for which no common source has yet been identified, is ongoing.

[Clinical and diagnostic approaches to neurocysticercosis]. / Klinicki i dijagnosticki pristup neurocisticerkozi.

ETIOLOGY: Cysticercosis is a tissue infection caused by larvae of the cestode Taenia solium. Neurocysticercosis is a central nervous system form of this infection. Taenia solium invades tissues in a form of a cyst with a thin, semitransparent wall. It can reach 1-2 cm in diameter in muscles and brain tissue and up to 3-6 cm in brain chambers. EPIDEMIOLOGY: Pigs are the most common intermediate hosts. The infection occurs when the parasite eggs or proglottids are ingested. It is most common in regions where human feces is used as a fertilizer, or regions with poor sanitary conditions. The man is infected with contaminated food or water, or by autoinoculation. PATHOGENESIS: The Taenia solium eggs are hatched in the duodenum. Embryos invade the intestinal mucosa, and reach various parts of the body, disseminated by the blood circulatory system. The most common localizations of cysticerci are skeleton, muscles and brain. While alive, these cysts produce a minimal reaction in hosts. Inflammation occurs when they die, often a few years after infection. CLINICAL FEATURES: While presence of adult worms of Taenia solium in the gastrointestinal tract causes unspecific symptoms, clinical features of neurocysticercosis depend on the number, size and localization of cysts, as well as on the degree of granulomatous response. The most common manifestations of this infection are epileptic seizures, whereas intracranial pressure increase can be the earliest sign of the disease. Hydrocephalus, meningitis and spinal cord compression syndrome are the most usual complications. PROGNOSIS: The death rate is low in neurocysticercosis with parenchymal cysts and calcification without hydrocephalus. However, fatal outcome occurs in hydrocephalic patients, cases with huge supratentorial cysts, multiple granuloma, brain edema or cerebral infarctions. DIAGNOSIS: Informations about travels to endemic regions are valuable in diagnosing neurocysticercosis. Cytobiochemical finding of the cerebrospinal fluid is often normal. However, in 50% of patients, lymphocytic or eosinophilic pleocytosis is found, low glucose (in 25%) and elevated protein (in 40% of cases). Further testing includes serologic examination of blood and cerebrospinal fluid. Finding of specific antibodies in the sera or cerebrospinal fluid confirms the diagnosis, although false positive reaction may occur in patients with other helminths, especially other cestode. The enzyme-linked immunotransfer blot assay is proven to be sensitive and specific in patients with multiple cysticerci. Computerized tomography and magnetic resonance imagining are techniques mostly used in establishing neurocysticercosis. They reveal the localization of cysticerci, identify the atrophic or edematous fields and assess the degree of ventricular dilatation.

[Clinico-epidemiologic characteristics of Lyme disease treated at the Infectious Disease in Novy Sad 1993-1998]. / Klinicko-epidemioloske karakteristike lajmske bolesti lecenih na Klinici za infektivne bolesti u Novom Sadu u periodu 1993-1998. godine.

INTRODUCTION: Borrelia burgdorferi, the etiological agent of Lyme disease, is transmitted by the bite of Ixodes ricinus, registered in all parts of Yugoslavia. Vectors are very active in spring and early summer and the disease has a seasonal distribution. Generally speaking, there are three defined stages of the disease, but some of them can be misdiagnosed or really absent. Serological analysis of Lyme disease is very difficult to interpret, especially in later stages, so confirmation by immunoblot assays is recommended. The aim of this study was to present some epidemiologic and clinical characteristics of Lyme disease in Vojvodina in the period from 1993-1998. Throughout this period, 1.659 persons with tick bite were registered, whereas 560 with diagnosed Lyme disease have been treated at the Clinic for Infectious Diseases in Novi Sad. RESULTS: In 511 patients (91.25%) we registered the first stage of the disease, in 42 (7.50%) the second stage and in 7 (1.25%) the third stage of the disease. The mean age of patients with erythema migranes was 38.67 years, mean incubation period was 9.37 days, and tick was removed from the skin after 2.29 days on average. Most of the identified tick bites originated from suburban areas (50.29%), they predominantly occurred in May and June (63.01%), and most of the ticks were removed improperly (57.67%). Dominant clinical manifestations of the second stage were acute meningitis (9.52%), Bannwarth's syndrome (9.52%), arthralgia and arthritis (50%), skin lesions (14.28%), cardiac disorders (11.90%) and mild liver lesions (2.38%) and generalized lymphadenopathy (2.38%). Chronic neuroborreliosis (42.85%), acrodermatitis chronica atrophicans (28.57%) and chronic arthritis were dominant clinical manifestations of the third stage. Up to 81.63% of patients with late stage of disease had a history of previous tick bite. One third of patients were asymptomatic in the first stage of the disease. Improper treatment of the first stage resulted in development of late stage disease in 57.14% of patients. CONCLUSIONS: Morbidity of Lyme disease in Vojvodina is about 1.98-9.8 cases on 100.000 inhabitants, and it belongs to regions with low incidence. Majority of bites are registered during summer months arround cities. Longer persistence of vector on the skin is a risk factor for manifested diseases. Inappropriately treated or completely untreated persons have higher risk for disseminated infection. In our country, most common manifestations of the second stage are neurological and articular manifestations as in the third stage. Leading symptoms and epidemiology aren't enough for diagnosis of Lyme disease, and more specific and sensitive serologic assays are necessary.

[Neurotrichinosis]. / Neurotrihineloza.

INTRODUCTION: Trichinellosis is an anthropozoonosis caused by Trichinella spiralis. Central nervous system complications can occur during the course of this disease. This paper presents a case of neurotrichinellosis, assayed by using indirect immunofluorescence test. CASE REVIEW: A patient aged 30, was admitted to the Clinic on the fifth day after onset of the disease, which was gradual, starting with flu-like symptoms. Two days before admittance, the diseased became somnolent, disconcerted and disoriented. On admission, the patient was highly febrile (39 degrees C), dehydrated, with eyelid edema. Right hemiparesis was present. The disease was confirmed by indirect immunofluorescence test, showing an increase of trichinella antibody titre (1:20, 1:160 and 1:640). The cerebrospinal fluid was cytobiochemically normal. Electroencephalographic findings exhibited a moderate cerebral dysfunction. Multifocal unspecific changes were established by magnetic tomography. The diseased was treated by mebendazole and prednisolone. The course of the disease was favourable and the patient was cured without sequelae. DISCUSSION: Recognition and diagnosis of Trichinellosis are complicated due to its polymorphid symptomatology. In the case reviewed, the disease started with clinical features of flu-like symptoms and febrile gastroenteritis. According to some authors, central nervous system manifestations occurred in 10-15% of the diseased. CONCLUSION: When examining clinically manifested encephalitis, Trichinelosis should be taken into consideration as a cause of the disease.

[Influenza--always present among us]. / Influenca--stalno medu nama.

INTRODUCTION: Influenza virus infects about 10 million persons worldwide each year. Two important characteristics of influenza are its epidemic outbreak and high mortality rate, mostly caused by complications. Influenza virus is characterised by a great antigenic variability. Major modifications, called antigenic shifts or type changes, occur approximately three times per century and result in worldwide epidemics--pandemics. Minor modifications, called antigenic drifts or strain changes demand new vaccine compositions each year. HISTORY: Pandemics and epidemics caused by influenza virus, such as the "Spanish Flu", the "Asian Flu", the "Hong Kong Flu" killed many people worldwide. Presently the epidemic, caused by influenza A virus Sydney/97 H3N2 is spreading over USA and most of Europe, including Yugoslavia. EPIDEMIOLOGY AND CLINICAL FEATURES: In humans influenza virus spreads over respiratory secretions, thrown out by coughing and sneezing. Children and older people, as well as immunosuppressed patients are prone to the infection. The onset of illness is sudden, with fever usually over 39 degrees C. Headache and myalgia are prominent. Other signs include fatigue, sore throat, nasal congestion and red eyes. Cough is a very important symptom, which starts as dry and progresses to wet with thick mucous. COMPLICATIONS: Pneumonia is the main cause of death among the high-risk patients. Bronchitis and tracheobronchitis also occur. Croup is a serious complication, often encountered in small children. Cardiac complications, especially myocarditis, are described as influenza complications. Neurological complications include encephalitis, encephalopathy, myelitis, Guillain-Barré syndrome, Reye syndrome, etc. Neurotropism of the influenza virus is under investigation. DIFFERENTIAL DIAGNOSIS AND DIAGNOSIS: Differential diagnosis of influenza includes all diseases which exhibit by increased body temperature, cough, headache, sore throat, myalgia and lethargy. Among serious diseases, pneumonia, sepsis, and meningitis should be considered. Various tests are used when diagnosing influenza: antigen detection, polymerase chain reaction, immunofluorescent tests, etc. THERAPY: Treatment of influenza by antiviral drugs can be prophylactic and therapeutic. Amantadine and rimantadine are older drugs effective in cases caused by virus type A. The newest generation of influenza antiviral agents are neuraminidase inhibitors--zanamivir and oseltamivir, effective against both virus types. The symptomatic therapy is still a basis of influenza treatment. PREVENTION: The main means of influenza prevention is a yearly vaccine. The three-valent vaccine is in common use. It is recommended that high-risk population should be vaccinated. If the composition of the vaccine is well matched with the prevalent virus strain, it is efficient in 50-80% of vaccinees. CONCLUSION: Influenza is the sixth cause of death in the world, the forth among the older population. The next pandemic can occur at anytime. It will be a different virus subtype, never before encountered by humans. Are we ready?

[Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease)]. / Histiocitni nekrotizirajuci limfadenitis (Kikuchi-Fujimotova bolest).

INTRODUCTION: Histiocytic necrotizing lymphadenitis is a disease of unknown etiology, favourable course and outcome, mostly encountered in young women. It exhibits increased temperature and lymphadenopathy. The illness resolved spontaneously after a few months. A CASE REVIEW: In a 32-year-old patient the disease developed gradually, with pain in the right axilla, within enlarged lymph. Two weeks later, her temperature increased to 39 degrees C, accompanied by fever, shivering, malaise and loss of appetite. The ultrasonographic finding showed a conglomerate of hypoechogenic lymph nodes, with a few enlarged lymph glands. By immunohistochemical examination of a gland tissue sample the diagnosis was established Kikuchi-Fujimoto disease ("Histiocytica necrotizing lymphadenitis"--"Apoptotic lymphadenitis"). Corticosteroid therapy had been administered for one year, which resulted in both subjective improvement and regression of enlarged lymph nodes. DISCUSSION: A connection between this disease and viruses has not been proved. Presence of intracellular tubuloreticular formations suggests autoimmune etiology of histiocytic necrotizing lymphadenitis. It is considered as hyperimmune reaction of the organism induced by a viral infection. Differential diagnosis should consider taxoplasmosis, tuberculosis, lymphadenitis and malignant lymphoma. CONCLUSION: Although histiocytic necrotizing lymphadenitis is a rare disease, this case shows that it should be considered when lymphadenopathy, particularly cervical, occurs in young women, accompanied by increased temperature.

[Meningoencephalitis as the only manifestation of Epstein-Barr virus infection]. / Meningoencefalitis kao jedina manifestacija infekcije Epstein-Barrovim virusom.

INTRODUCTION: Epstein-Barr virus (EBV) infection is most often manifested as infective mononucleosis, which exhibits fever, tonsillopharyngitis, lymphadenopathy and hepatospleenomegaly, and presence of leucocytosis with lymphocytosis in the complete blood count. Neurological manifestations are rarely seen during EBV infection, in less than 1% of the diseased, most often under the features of serous meningitis, encephalitis, encephalomyelitis, transversal myelitis, neuritis, polyradiculoneuritis, convulsions etc. PATIENTS AND METHODS: The aim of the study was to investigate the frequency and clinical features of neurological manifestations in EBV infected patients treated at the Clinic for Infectious Diseases. Clinical Centre Novi Sad, during 1997. Etiologic diagnosis was confirmed by establishing presence of the viral capsid antigen specific antibodies--EBV VCA, IgM and IgG class, in the blood and cerebro-spinal fluid, as well as according to the dynamics of their titre. RESULTS: Most patients (94.64%), had the classic features exhibited by fever, angina, polylymphadenopathy and hepatospleenomegaly, while 5.36% of patients had neurological symptoms, that is meningoencephalitis as the only manifestation of EBV infection. Besides antibodies in sera, EBV antibodies in the cerebro-spinal fluid had been proved in these patients. In all patients, other viral etiology of meningoencephalitis had been excluded by serologic blood examination. Bacterial findings in the cerebro-spinal fluid had been negative as well. The outcome of the illness was favourable in all patients.

[Herpes simplex and lymphocytic choriomeningitis viruses in infections of the central nervous system--clinical and cerebrospinal fluid characteristics]. / Virusi herpesa simpleks i limfocitarnog horiomeningitisa u infekcijama centralnog nervnog sistema--klinicke i likvorske karakteristike.

INTRODUCTION: A great number of various viruses are stated as the cause of acute infections and damages of the central nervous system. In most cases these are minor damages which exhibit as meningeal syndrome and a specific finding in the cerebrospinal fluid. According to the dominant location, central nervous system infections can take a form of meningitis, encephalitis or myelitis. Since the inflammatory process of the meninges can not be separated from the inflammatory process of the brain, we usually speak of meningoencephalitis. The etiological diagnosis of meningitis and encephalitis is established by isolating the virus from the cerebrospinal fluid and by finding the presence of the specific antibodies in the blood and in the cerebrospinal fluid. The most common causes of the viral meningitis are Enteroviruses, the Mumps virus, Arthropode borne viruses, the Herpes viruses, Adeno viruses and the Lymphocytic choriomeningitis virus. The aim of our study was to establish the correlation between the clinical features and immunological and cerebrospinal fluid changes and the degree of the damage to the blood-brain barrier during the infections of the central nervous system, caused by the Herpes Simplex virus and the Lymphocytic choriomeningitis virus. MATERIAL AND METHODS: From a group of 103 patients, who had been treated for viral meningitis and meningoencephalitis, a group of 27 patients with established specific viral etiology--Herpes Simplex virus and Lymphocytic choriomeningitis virus, had been taken into the account. Herpes Simplex infection had been proven by the complement binding reaction and the neutralisation test of the even samples of serum. The diagnosis of Lymphocytic choriomeningitis was confirmed by the immunofluorescence test of the pharynx swabs and cerebrospinal fluid. The clinical features, such as body temperature, encephalitic signs, and electroencephalographic findings had been followed and compared. RESULTS: Herpes Simplex infection had been found in 20 patients, Lymphocytic choriomeningitis had been proven in 7 patients. All the patients had increased body temperature. Only four of the patients exhibited encephalitic signs, all infected by the Herpes Simplex virus. Patients from the Herpes Simplex group showed various degrees of consciousness disturbances, ranging from somnolence to coma, while the Lymphocytic choriomeningitis patients exhibited none. Higher pleocytosis and protein level had been found in the Lymphocytic choriomeningitis group. DISCUSSION: Viral diseases of the central nervous system are the result of the direct damage of the brain and meninges by the virus and immunological processes. Herpes Simplex meningitis usually has a good prognosis. Lymphocytic choriomeningitis has longer course of the disease and exhibits more severe clinical features. CONCLUSION: In cases of the central nervous system infections, caused by Herpes Simplex virus or Lymphocytic choriomeningitis virus, the correlation between the severeness of clinical features and the degree of damage of the blood-brain barrier, the level of pleocytosis and the increase of the cerebrospinal fluid proteins had been established.

[Leishmaniasis: case report]. / Lejsmanioza: prikaz slucaja.

INTRODUCTION: Leishmaniasis is a chronic parasitic disease of the reticuloendothelial system which is manifested by gradual onset, unspecific disorders and can take a form of visceral, cutaneous or mucocutaneous leishmaniasis. The aim of the study is to present the patient who was treated for visceral leishmaniasis at the Clinic for Infectious Diseases in Novi Sad. CASE REPORT: A patient, 22 years old, had been admitted at the Clinic one month after the beginning of the disease with gradual onset malaise, fatigue, loss of appetite, intermittent temperature and night sweating. A few days before the admittance to the hospital, dark colour of urine and the pain under the left rib occurred. On admission, the patient had been afebrile, dehydrated, intoxicated, he had subicteric sclerae with enlarged liver and extremely enlarged spleen. Laboratory findings revealed anemia, leucopenia, and increased level of gamma globulins. Hypercellularity of the bone marrow with cells of all degrees of maturity had been determined by sternal puncture. We have epidemiologically obtained information about the bites of a mosquito from the Phlebotomus genus at the Adriatic coastal region, two years and two months ago. The diagnosis had been confirmed by the formol-gel test and by the indirect hemaglutination test. Leishmaniae donovani had been found in the bone marrow punctate. TREATMENT: The patient had been treated by appropriate doses of N-methyl-glucamine-antimonate (Glucantime), during three weeks, after which he was cured. During the one-year follow-up period normalization of laboratory findings as well as liver and spleen ultrasonographic findings occurred. CONCLUSION: Because of gradual onset and polymorphic troubles during the beginning of leishmaniasis, many diseases can be taken into account for diagnostic differentiation. From this study it is obvious that even the possibility of such a disease must be considered, despite the fact that it is rare in our region, because fatal outcome is avoidable only by the timely diagnosis and therapy.

[Chronic meningitis]. / Hronicni meningitis.

The paper presents the past knowledge of the etiology of chronic meningeal syndrome. The causes are divided into those of infective and those of noninfective etiology. Basic recommendations for general diagnostic approach, laboratory, clinical and radiological follow up of the patients have been given. A wide spectrum of differential-diagnostic possibilities has been pointed out, especially in relation to chronic systemic diseases. Characteristic syndromes of chronic meningitis have been separated and concisely described.