Aggelos Stefos

Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome.

BACKGROUND Spontaneous spondylodiscitis is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality. We conducted a prospective case study over a 2-year period in order to analyze the clinical features, approaches to management, and outcome of spondylodiscitis. METHODS Eight consecutive patients (four men, four women; age range 53-82 years) suffering from spondylodiscitis were identified during the study period. Parameters recorded included: demographics, past medical history, predisposing factors, presenting signs and symptoms, spinal level and extension of the infection, laboratory indices of inflammation, microbiological testing, radiological assessment, kind and duration of treatment, follow-up magnetic resonance imaging (MRI) studies, and outcome. RESULTS Duration of symptoms varied from 14 to 90 days. All patients had back pain; fever>or=38 degrees C was present in 5/8 (62.5%) and neurological findings in 6/8 (75%). Diabetes mellitus was identified in six (75%). Most of the patients had elevated laboratory markers of inflammation. At the initial MRI, 12 anatomical levels were found. The microorganism was identified in 7/8 by blood or bone marrow cultures (50% Staphylococcus aureus). None of the patients underwent surgical intervention. Seven patients (87.5%) recovered to full activity; follow-up MRI study results were not always in parallel with the clinical improvement of patients. CONCLUSIONS Spontaneous spondylodiscitis should be considered in every patient with back pain accompanied by fever and laboratory markers of inflammation. The major predisposing risk factor seems to be uncontrolled diabetes. MRI appears to be the method of choice for confirming diagnosis. Timely and accurate diagnosis along with prompt administration of antibiotics appears mandatory for a favorable outcome and avoidance of surgical intervention.

Hepatitis B virus reactivation in hepatitis B virus surface antigen negative patients receiving immunosuppression: A hidden threat

AIM To present the characteristics and the course of a series of anti-hepatitis B virus core antibody (HBc) antibody positive patients, who experienced hepatitis B virus (HBV) reactivation after immunosuppression. METHODS We retrospectively evaluated in our tertiary centers the medical records of hepatitis B virus surface antigen (HBsAg) negative patients who suffered from HBV reactivation after chemotherapy or immunosuppression during a 3-year period (2009-2011). Accordingly, the clinical, laboratory and virological characteristics of 10 anti-HBc (+) anti-HBs (-)/HBsAg (-) and 4 anti-HBc (+)/antiHBs (+)/HBsAg (-) patients, who developed HBV reactivation after the initiation of chemotherapy or immunosuppressive treatment were analyzed. Quantitative determination of HBV DNA during reactivation was performed in all cases by a quantitative real time polymerase chain reaction kit (COBAS Taqman HBV Test; cut-off of detection: 6 IU/mL). RESULTS Twelve out of 14 patients were males; median age 74.5 years. In 71.4% of them the primary diagnosis was hematologic malignancy; 78.6% had received rituximab (R) as part of the immunosuppressive regimen. The median time from last chemotherapy schedule till HBV reactivation for 10 out of 11 patients who received R was 3 (range 2-17) mo. Three patients (21.4%) deteriorated, manifesting ascites and hepatic encephalopathy and 2 (14.3%) of them died due to liver failure. CONCLUSION HBsAg-negative anti-HBc antibody positive patients can develop HBV reactivation even 2 years after stopping immunosuppression, whereas prompt antiviral treatment on diagnosis of reactivation can be lifesaving.

Descriptive epidemiology of chronic hepatitis B by using data from a hepatitis registry in Central Greece

BACKGROUND In Greece, there are few data on the epidemiological characteristics of HBV. Our aim was to study the epidemiological patterns of HBV in Central Greece and identify the possible differences in HBV prevalence (clusters) among areas inside this region using data from the hepatitis registry. METHODS The study was performed in Thessaly, one out of the thirteen regions of Greece and covers most of the part of Central Greece. A total of 921 HBV patients were registered in the hepatitis registry during the period 1999-2004 while 303 were randomly selected to be studied further using a detailed questionnaire on several epidemiological factors. RESULTS 187/303 patients (61.7%) classified as chronic inactive HBV carriers, 78/303 (25.7%) had chronic hepatitis B, 29/303 (9.6%) had HBV-related cirrhosis and 9/303 (3%) HBV-related hepatocellular carcinoma (HCC). The route of HBV transmission was vertical in 103 (34%), sexual in 46 (15.1%) and intrafamilial in 98 (32.4%). Folk remedies were identified as the predisposing risk factor for contracting HBV infection in 38 (12.5%), previous transfusion in 9 (3%) and unknown mode of transmission in 9 patients (3%). Alcohol abuse was the only independent factor (OR: 2.5; p=0.01) associated with the progression to cirrhosis-HCC. There were specific areas (clusters) inside Thessaly region with increased ratio of HBV infection; Vertical and sexual modes of transmission were more prominent in some of these areas. CONCLUSIONS Vertical, intrafamilial and sexual modes of HBV transmission identified as the major routes of HBV infection in our study. We also identified cluster areas of HBV infection in Central Greece. Alcohol abuse is frequent among HBV patients and is acting as an effect modificator risk factor for the development of HBV-related cirrhosis and HCC. Extended population studies in Greece are needed to assess in detail the epidemiological patterns of HBV and evaluate control programmes.

Unusual cardiovascular complications of brucellosis presenting in two men: two case reports and a review of the literature

IntroductionBrucellosis is a zoonosis with worldwide distribution, which is particularly endemic in many countries of the Mediterranean basin. Cardiovascular complications of this disease, such as endocarditis, myocarditis and pericarditis, are very rare, with even fewer cases of myocarditis or asymptomatic pericardial effusion in the absence of concomitant endocarditis being reported.Case presentationWe report two cases of brucellosis in two Caucasian men, aged 17 and 34 years old, with myocarditis and asymptomatic pericardial effusion, respectively. Of note, neither patient had concomitant endocarditis. The disease was confirmed serologically and by blood cultures. Both patients recovered completely after receiving appropriate antibiotic treatment without any sign of relapse during a follow-up of 12 months.ConclusionThese two cases emphasize that in endemic areas Brucella can be considered as a potentially causative agent of idiopathic pericardial effusion or myocarditis, even in the absence of concomitant endocarditis. This possibility could be taken into account particularly in cases where contraction of brucellosis is possible, such as occupational exposure or consumption of unpasteurized dairy products.

Current clinical, laboratory, and treatment outcome characteristics of visceral leishmaniasis: results from a seven-year retrospective study in Greece

OBJECTIVES Visceral leishmaniasis (VL) is re-emerging in endemic areas. The epidemiological, clinical, laboratory, and treatment outcome characteristics in a large cohort of VL patients is described herein. METHODS The cases of 67 VL patients (57% male, mean age 56 years) treated in two Greek hospitals over the last 7 years were identified and evaluated retrospectively. RESULTS Forty-six percent of patients reported contact with animals. Seventeen patients (25%) were immunocompromised, and 22% were co-infected with another pathogen. Sixty-four percent of patients had fever, 57% had weakness, 37% had sweats, 21% had weight loss, and 13% had a dry cough, while 6% developed haemophagocytic syndrome. The median duration of symptoms was 28 days. Fifty-eight percent of patients had splenomegaly, 49% had hepatomegaly, and 36% had lymphadenopathy. The diagnosis was established by positive PCR in peripheral blood (73%) and/or bone marrow specimens (34%). Sixty-one patients (91%) received liposomal amphotericin (L-AMB). Six patients (10%) did not respond or relapsed but were eventually cured after a second cycle of L-AMB. During a 6-month follow-up, the overall mortality was 9%, although none of these deaths was attributed to VL. CONCLUSIONS VL is still a common disease in endemic areas, affecting immunocompetent and immunocompromised patients. Its diagnosis is challenging, and molecular techniques are valuable and helpful tools to achieve this. Treatment with L-AMB is safe and very effective.

Progression into sepsis: an individualized process varying by the interaction of comorbidities with the underlying infection

BackgroundDevelopment of sepsis is a process with significant variation among individuals. The precise elements of this variation need to be defined. This study was designed to define the way in which comorbidities contribute to sepsis development.MethodsThree thousand five hundred nine patients with acute pyelonephritis (AP), community-acquired pneumonia (CAP), intraabdominal infections (IAI) or primary bacteremia (BSI) and at least two signs of the systemic inflammatory response syndrome were analyzed. The study primary endpoint was to define how comorbidities as expressed in the Charlson’s comorbidity index (CCI) and the underlying type of infection contribute to development of organ dysfunction. The precise comorbidities that mediate sepsis development and risk for death among 18 comorbidities recorded were the secondary study endpoints.ResultsCCI more than 2 had an odds ratio of 5.67 for sepsis progression in patients with IAI between significantly higher than AP and BSI. Forward logistic regression analysis indicated seven comorbidities that determine transition into sepsis in patients with AP, four comorbidities in CAP, six comorbidities in IAI and one in BSI. The odds ratio both for progression to sepsis and death with one comorbidity or with two and more comorbidities was greater than in the absence of comorbidities.ConclusionsThe study described how different kinds of infection vary in the degree to which they lead to sepsis. The number of comorbidities that enhances the risk of sepsis and death varies depending on the underlying infections.

HEPATOCELLULAR CARCINOMA: CLINICAL CHARACTERISTICS OF THE DISEASE IN CENTRAL GREECE

and need for adrenaline, atropine and intubation were associated with poor outcomes. Witnessed arrests had favorable immediate outcome (p<0.01). In cases with primary respiratory arrests successful resuscitation was achieved in 90% and 1-year survival was 76%. There was no statistically significant difference in survival with increasing age. Conclusions: The initial, 1-month and 1-year survival following CPR were 37.9%, 24% and 16% respectively. Early recognition of critically ill patients, nursing in monitored areas and effective advanced life support training may be improving outcomes in our hospital.

SERIAL ANALYSIS OF AUTOANTIBODIES IN PATIENTS WITH PRIMARY BILIARY CIRRHOSIS

BACKGROUND / AIMS Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease characterized by progressive destruction of small intrahepatic bile ducts, with portal inflammation, leading to fibrosis and cirrhosis. It is a model autoimmune disease characterized by highly specific autoantibodies, strong female predominance and coincidence of other autoimmune conditions. Many efforts are focused on the field of non-invasive markers, in order to allow a more accurate diagnosis and predict disease severity. The characteristic immunological feature of PBC is the presence of antimitochondrial antibodies (AMA), which are detected in more than 90% of patients, even long before the disease is clinically overt. However, in general AMA lack of prognostic value and do not determine clinically different groups of patients while their changes in titers are not related with disease progression. New autoantibodies continue to be characterized, in the hope of defining markers of disease progression and treatment outcome. During the last years, there is an increasing interest about the frequency and significance of antinuclear antibodies (ANA) in PBC. Among these, antibodies against the nuclear pore membrane glycoprotein (anti-gp210) and against the nuclear protein sp100 (anti-sp100) are highly specific for PBC and can be regarded as additional diagnostic markers. In addition, they have been identified as negative prognostic factors. However, the serial changes of these autoantibodies and the correlation with natural history of PBC and response to treatment with ursodeoxycholic acid (UDCA) have not fully assessed. The aim of the present study was to assess the clinical utility of the presence and serial changes in titers of AMA, ANA-PBC-specific (anti-gp210 and anti-sp100) anti-chromatin antibodies. PATIENTS & METHODS One hundred and ten patients with PBC were followed for a mean duration of 39.9±23 months at the outpatient clinic of the Department of Medicine, Larissa Medical School, University of Thessaly, Larissa, Greece. During this period 512 samples were collected and investigated for the presence of AMA IgG/IgA classes, anti-gp210, anti-sp100 and anti-chromatin, by commercial ELISAs. Biochemical, clinical and histological status at initial presentation and during follow-up visits were included. The Mayo risk score was calculated as a prognostic index at each time point. Liver biopsy were classified according to Ludwig’s classification and biochemical response to ursodeoxycholic acid (UDCA) was evaluated according to Pares criteria.