Spondylodiscitis associated with recurrent Serratia bacteremia due to a transjugular intrahepatic portosystemic shunt (TIPS): a case report.

We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection.

Mediterranean spotted fever: case series of 24 years (1989-2012).

PURPOSE: Mediterranean spotted fever (MSF) is the most prevalent zoonosis in Portugal. To characterize it's evolution between 1989 and 2012, the authors reviewed the cases diagnosed at their unit during this period. METHODS: Review of clinical records of patients with MSF diagnosis, between 1989 and 2012. RESULTS: Data from 250 patients was included, 54% male. Mean age at diagnosis was 58 years (11-92). Mean annual incidence was 10 cases, with clear summer predominance. Most patients, 78% lived in rural areas, 34% had contact with dogs and 10% noticed the tick bite. Most common symptoms were: fever (98%), myo-arthralgia (64%) and headache (48%). Maculopapular rash was noticed in 87%, affecting palms in 77% and soles in 69%. Inoculation eschar was found in 60%, mostly located on the trunk. Treatment included doxycycline in 86% and chloramphenicol in 12%, with a mean duration of 8 days. Most frequent blood test abnormalities were C-reactive protein, lactate dehydrogenase, aspartate aminotransferase and alanine transaminase elevations and thrombocytopenia. First serologic evaluation was positive in 37% (78/212), having seroconversion been documented in 85% (72/85). Most frequent complication was acute renal injury. ICU admission occurred in 5%. Average length of hospital stay was 11.2 days (1-106), with a mortality of 3.6%. CONCLUSIONS: In our series, there was clear summer predominance of MSF, which had rural origin in 78%. Most common symptoms were fever, myo-arthralgia and headache. Maculopapular rash was noticed in 87% of cases and inoculation eschar in 60%. Most cases had favourable outcome, having 5% been admitted to ICU. Mortality was 3.6%.

One year of Lamivudine therapy for portuguese patients with chronic hepatitis B.

OBJECTIVE: To assess the efficacy of lamivudine treatment on hepatitis B e antigen (HBeAg) and/or hepatitis B surface antigen (HBsAg) seroconversion, on other virological and serological markers of response including hepatitis B virus (HBV) DNA and serum aminotransferases, and the safety of lamivudine treatment in hepatitis B patients. PATIENTS: This phase III open-label study evaluated the virological and biochemical response to lamivudine in 70 Portuguese patients with HBeAg positive chronic hepatitis B. Patients were treated with lamivudine 100mg once daily for 12 months. METHODS: Antiviral activity was assessed by measuring alanine aminotransferase (ALT)/aspartate aminotransferase (AST) levels at all protocol visits, and hepatitis B serology and HBV DNA were performed at baseline and at month 12 visits. Evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses. RESULTS: The primary endpoint was virological response at month 12, defined as loss of detectable HBeAg from serum with a reduction of HBV DNA to undetectable levels, and this was observed in 19/69 (27.5%) of patients. Almost half of the patients were HBV DNA negative by this time. Mean ALT values decreased steadily during treatment and by 12 months 61% of patients had values within the normal range. HBeAg seroconversion (HBeAg negative, HBeAb positive) was achieved in 27.9% of patients by 12 months, although all patients remained HBsAg positive. CONCLUSION: Lamivudine was well tolerated and the incidence of adverse events was similar to those reported in previous studies. Lamivudine treatment resulted in virological and biochemical improvements in HBeAg positive chronic hepatitis B patients, with HBeAg seroconversion in one-third of patients.

[Liver involvement in HIV infection and various parasitic diseases]. / Comprometimento hepático no decurso da infecção pelo VIH e por algumas parasitoses.

During the course of systemic infections, the liver is an organ which is frequently involved. The pathology of the human immunodeficiency virus with all its infections, opportunistic tumours and some parasitoses, such as amebiasis, kala-azar, hydatidosis, schistosomiasis and fascioliasis, evolve into hepatic compromise. This development is what we attempt to summarise.

[The treatment of cytomegalovirus retinitis in human immunodeficiency virus infection]. / Tratamento da retinite pelo virus citomegálico na infecção pelo vírus da imunodeficiência humana.

Most of the patients with immunodeficiency virus infection (75%-85%) are coinfected with cytomegalovirus. It is estimated that cytomegalovirus disease develops in 45% of them, mainly those presenting low CD4 cell counts (< 100/mm3). Retinitis is the most common manifestation of reactivated cytomegalovirus disease (85%), followed by other extra ocular sites (central nervous system, lungs, gastrointestinal system, adrenal glands, etc.). The particularly high incidence of cytomegalovirus retinitis, the difficulties concerning its therapeutical approach and the relatively unsatisfactory results, justify this review, according to the new treatment options presented in recent literature.

Comparative study of various biological markers in infection by HIV1.

A study was performed on 51 human immunodeficiency virus (HIV-1)-infected patients with a previous history of drug abuse. By the CDC staging system for HIV infection they were mainly in advanced stages of that infection, 67% were in IV-A and 8% in IV-CI. Patients were divided in two groups, one composed of 33 individuals who needed AZT therapy and the other of those who did not need that medication (18 patients). Between 3 and 18 months several parameters were assessed on 3 different occasions, according to standard techniques: red blood cells and platelet numeration, CD4 and CD8 cell counts, HIV antigen (p24 Ag), beta 2-microglobulin, high-density serum lipoproteins (HDL), and anticardiolipin antibodies (ACA). In the patients treated with AZT the first bioserologic evaluation was performed before starting this therapy. Finally it was observed that p24 AG and ACA were present in 21% of the patients, all of them in advanced stages of HIV infection and under AZT therapy. A significant correlation was only found between CD4 counts and beta 2-microglobulin (R = 0.34; P = 0.0001).

[Comparative study of various biological markers in HIV 1 infection]. / Estudo comparativo de vários marcadores biológicos na infecção HIV1.

A study was performed on 51 human immunodeficiency virus (HIV 1)-infected patients with a previous history of drug abuse. By the CDC staging system for HIV infection they were mainly in advanced stages of that infection, 67% were in IV-A and 8% in IV-C1. Patients were divided in two groups, one composed of 33 individuals who needed AZT therapy and the other of those who did not need that medication (18 patients). Between 3 and 18 months several parameters were assessed on 3 different occasions, according to standard techniques: red blood cells and platelet numeration, CD4 and CD8 cell counts, HIV antigen (p24 Ag), beta 2-microglobulin, high density serum lipoproteins (HDL), and anticardiolipin antibodies (ACA). In the patients treated with AZT the first bioserologic evaluation was performed before starting this therapy. Finally it was observed that p24 AG and ACA were present in 21% of the patients, all of them in advanced stages of HIV infection and under AZT therapy. A significant correlation was only found between CD4 counts and beta 2-microglobulin (R = 0.34; P = 0.0001).

[The prevalence of measles, rubella, mumps and chickenpox antibodies in a population of health care workers]. / Prevalência dos anticorpos anti-sarampo, rubéola, papeira e varicela numa população de trabalhadores da saúde.

We present an epidemiological and serological study in 409 health care workers randomly selected from the 4,103 workers of the University Hospital of Coimbra. A low level of susceptibility for measles (1.2%; 95% confidence interval (95% CI): 0.15-2.23%), rubella (2.4%; 95% CI: 0.9-3.9) and varicella (3.2%; 95% CI: 1.5-4.7%) and a very high one for mumps (17.3%; 95% CI: 13.7-21.1%), were found. Ineffectiveness of historical information in predicting immune status to all of these diseases was found. An economic analysis of preventive measures was done. A mumps vaccination policy for health care workers is recommended and the opportunity of measles and rubella vaccination is discussed, facing the results of this study. Continuous monitoring of these diseases is needed anticipating the changes in epidemiology that are expected to occur with childhood vaccination.

[Spinal brucellosis. 4 years of experience]. / Espondilite brucélica. Quatro anos de experiência.

The Authors retrospectively studied 17 patients who have been admitted to the Infectious Diseases Clinic of Coimbra University Hospital during a four year period and whose final diagnosis was brucellar spondylitis. Clinical, epidemiological, laboratory and imaging features are analyzed, as well as those related to the therapeutic schedules and outcome. Females were more often affected (70.58%) and the mean age was 53.35 +/- 13.82 years. Lumbar spine was most frequently involved and an unusual elevated incidence of paravertebral soft tissue swelling was noticed (23.52%). Two patients were also suffering from neurobrucellosis (11.76%). The preferred therapeutic schedule was rifampin and doxycycline and surgery was performed in one patient. Finally, several comments are made regarding basically the incidence, laboratory and imaging diagnosis, therapeutic aspects and evolution of the disease. The imaging similarities and differences between tuberculous, pyogenic and brucellar spondylitis are briefly approached.

[The determination of susceptibility to measles, rubella, mumps and chickenpox in students of health-related areas]. / Determinação da susceptibilidade ao sarampo, rubéola, papeira e varicela nos estudantes das áreas ligadas à saúde.

We present an epidemiological and serological study in 286 health care students. We found susceptibility for measles in 11.7% individuals (95% confidence interval (95% CI): 8.0-15%), for rubella: 6.7% (95% CI: 3.8-9.6%) for mumps: 12.7% (95% CI: 8.0-16.6%) and for varicella 8.5% (95% CI: 5.3-11.7%). Compared to a similar study, performed in 1992 in a population of health care workers, we found an increasing susceptibility to these diseases except for mumps, that had decreased. Among those who received one dose of measles vaccine we found 12.1% non immune. We found an high level of immunity (97.1%) for those who received rubella vaccination. We could not draw any conclusions for mumps because only seven had been vaccinated.

Cerebral toxoplasmosis after renal transplantation. Case report and review.

Infection caused by Toxoplasma gondii is a frequent event in Portugal. When this occurs in immunocompetent individuals, it is rarely a matter of concern; the contrary occurs with immunosuppressed patients or in pregnancy. Transplant patients are treated with immunosuppressive drugs which mainly disturb their mechanisms of cellular immunity, and that opens the way to infections by opportunistic intracellular microorganisms. We recently treated a renal transplant patient who suffered from cerebral toxoplasmosis, and this provided an opportunity for a review of the other 20 patients reported in medical literature to date.

[Cerebral toxoplasmosis in a kidney transplant patient. A clinical case and review of the literature]. / Toxoplasmose cerebral em transplantado renal. Caso clínico e revisão da literatura.

Infection caused by Toxoplasma gondii is a frequent event in Portugal. When this occurs in immunocompetent individuals it is rarely a matter of concern; the contrary occurs with immunosuppressed patients or in pregnancy. Transplant patients are treated with immunosuppressive drugs which mainly disturb their mechanisms of cellular immunity, and that opens the way to infections by opportunistic intracellular microorganisms. We recently treated a renal transplant patient who suffered from cerebral toxoplasmosis, and this provided an opportunity for a review of the other 20 patients reported in medical literature to date.

The early days of pandemic (H1N1) 2009 virus infection in the central region of Portugal.

BACKGROUND: The first case of pandemic (H1N1) 2009 virus infection was diagnosed in the central region of Portugal on June 16, 2009, in a woman infected in Canada. METHODS: The aim of our study was, first to characterize the clinical and epidemiologic aspects of all the patients with clinical manifestations included in the definition of case for investigation with samples submitted to diagnosis of the pandemic (H1N1) 2009 virus infection, in the central region of Portugal; second to assess the precision of the case definition of case for investigation considered in the study according to the presence or the absence of fever at the moment of clinical observation. We reviewed the medical records of all the patients presenting with Influenza like-illness classified as case for investigation and the first cases of patients infected with the new pandemic (H1N1) 2009 virus, diagnosed in the central region of Portugal during the pandemic period between June and August, 2009, were analyzed. Real-time reverse-transcriptase polymerase-chain-reaction (RT-PCR) testing was used to confirm the pandemic (H1N1) 2009 virus infection. Data collection was performed on a standardized paper format in agreement with the General Health Directorate. RESULTS AND DISCUSSION: Pandemic (H1N1) 2009 virus infection was confirmed in 255 patients. Overall, median age was 23 years and 42.7 % were included in the category of 20 to 29 years. Confirmed infection in patients with less than 2 years or greater than 50 years was a rare event. The first cases were imported from Europe, namely France, Spain and England. On a second phase, pandemic (H1N1) 2009 virus infection was acquired in the south of Portugal (Algarve), before de diagnosis of the first domestic case. The incidence rate for pandemic (H1N1) 2009 virus infection was 10.7 per 100,000 persons and was different according to the district. It was higher in the district of Coimbra and Guarda were the main roads connecting to Europe are. The median calculated incubation period for the for pandemic (H1N1) 2009 virus infection was 2 days. The length of the clinical manifestations until the patients look for medical observation had a median time of 2 days. All the cases were of mild to moderate severity. No deaths were observed. CONCLUSIONS: The early days of pandemic (H1N1) 2009 virus infection was mild in our region. Most affected patients were young adults, with the extreme categories ages of life being spared. Early detection and diagnosis, combined with stringent isolation and treatment procedures could have slowed the spread of the infection in our region.

Miltefosine for visceral leishmaniasis relapse treatment and secondary prophylaxis in HIV-infected patients.

Miltefosine is the first effective oral drug against visceral leishmaniasis. However, there are few data about its role against the increasing problem of HIV-associated visceral leishmaniasis. It is necessary to establish a treatment and secondary prophylaxis approach with miltefosine in this population, particularly for those in whom standard treatment was unsuccessful. We report our experience with miltefosine in 5 HIV-infected patients. Miltefosine was used in relapse treatments (50 mg, b.i.d.) in 3 patients and as maintenance therapy (50 mg, 3 times/week) in all of them. Miltefosine was discontinued after full recovery of immune function in 4 patients. The median disease-free period has been 20 months since miltefosine discontinuation. One patient was lost to follow-up. Miltefosine dosage regimens for the treatment of relapses and for maintenance treatment in HIV-infected patients should be established in prospective studies.

[Visceral leishmaniasis and HIV infection in the HAART era]. / Leishmaniose visceral e infecção por vírus da imunodeficiência humana na era da terapêutica anti-retrovírica de alta eficacia.

Visceral Leishmaniasis is an endemic infection in Portugal, as well as in other Mediterranean basin countries, where it has become a frequent complication of HIV infection. There are several studies published about Leishmania/HIV co-infection, however some particularities of its epidemiology, pathogenesis and especially of its treatment and prophylaxis remain unclear and undefined. The authors review some aspects of this co-infection, particularly epidemiology, clinical classic manifestations and laboratory features, diagnosis, treatment, prophylaxis and prevention and report the casuistic of the Infectious Diseases Department of the University Hospital of Coimbra during the last ten years (1996-2006) in the HAART (<>) era. Visceral Leishmaniasis behaves as an opportunistic infection in HIV-infected patients and should be considered as an AIDS-defining disease. Nowadays and according to World Health Organization, VL is the second most important protozoan disease and one of the most neglected; therefore the establishment of treatment and prophylaxis guidelines is urgent.

[Effects of probucol on skin cholesterol concentrations in patients with type II hyperlipoproteineamia (author's transl)]. / Effets du probucol sur la teneur en cholestérol de la peau dans les hyperlipoprotéinémies de type II.

Twenty patients (14 male and 6 female) with hyperlipoproteineamia (type IIa in 10 and type IIb in 10) were given probucol 500 mg b.d. during 6 months. Eleven patients had xanthoma tendinosum and 4 had xanthelasma. The mean plasma cholesterol and plasma triglyceride levels were 435 +/- 100 mg/dl and 210 +/- 138 mg/dl respectively. Normal diet was continued throughout. Skin biopsies were performed on the forearm before and after treatment. The skin fragments were freeze-dried, and free (FCh) and esterified (ECh) cholesterol concentrations were measured by gas chromatography after preliminary thin layer chromatography on silica gel. FCh and ECh were found to be significantly increased before treatment when compared with skin concentrations in 10 control subjects; FCh ranged from 2.25 to 1.58 microgram/mg (p < 0.001) and ECh from 0.44 to 0.16 microgram/mg of dry tissue (p < 0.001). After 6 months' treatment with probucol, there was no significant change in FCh (2.25 to 2.16 microgram/mg), but a significant rise was observed in ECh (0.44 to 0.66 microgram/mg; p < 0.01). This effect suggests that probucol interferes with cholesterol synthesis and transport in human tissues, which might help to comprehend the action of this and other drugs on xanthelasma, xanthoma tendinosum and atherosclerosis. In one of the patients, a xanthelasma was considerably reduced in size following probucol treatment.

Study of free and esterified cholesterol in skin in atherogenic hyperlipidemias.

Free and esterified cholesterol in the skin were assayed by gas chromatography after thin layer histochromatographic separation. There were 20 controls of both sexes, 36 subjects with type lla hyperlipoproteinemia, 27 with type IIb hyperlipoproteinemia and 19 with type IV hyperlipoproteinemia. Esterified skin cholesterol levels were higher in women with the type of lla disorder and in subjects with tendinous xanthomas. The levels of esterified skin cholesterol in type II women is not correlated with free skin cholesterol or with total circulating cholesterol; all these parameters are correlated in men. Furthermore, skin cholesterol levels were determined in 15 type II subjects before and after a six month treatment with the anticholesterolemic probucol. Cholesterolemia decreased 10 per cent, free skin cholesterol decreased slightly and esterified skin cholesterol increased significantly, as did the esterified/total skin cholesterol ratio. These data suggest the existence of a relationship between low vascular risk and elevated levels of esterified skin cholesterol (or elevated esterified/total skin cholesterol ratio).

Spondylodiscitis associated with recurrent Serratia bacteremia due to a transjugular intrahepatic portosystemic shunt (TIPS): a case report

We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection.