Alina Cristina Neguț

Differential diagnosis of reactive arthritis in a patient with intravesical BCG immunotherapy

Case report We report the case of a 50 year-old female patient known with bladder tumor operated in January 2014 followed by 4 weeks of intravesical BCG immunotherapy, one administration per week. After each course the patient accused low grade fever, nausea, pollakiuria and hematuria with limited duration. In March 2014, after a cystoscopy and a bladder resection, she underwent another 5 weeks of BCG instillations. After the fourth course the patient presented to our clinic for fever with chills, pollakiuria, hematuria, conjunctivitis, myalgia and disabling migratory arthritis of the left ankle and right knee. Clinical exam at admission: high fever, left ankle and right knee arthritis, impaired mobility in the left temporomandibular joint. Following admission the patient developed left metacarpophalangeal and proximal interphalangeal arthritis of the index and medius. She had leukocytosis with neutrophilia, reactive thrombocytosis and high biologic inflammatory syndrome. Urinalysis showed frequent leukocytes, no albuminuria and negative cultures. The patient underwent arthrocentesis for synovial fluid sampling; the smear showed absence of bacteria, 40% polymorphonuclear cells, 15% small lymphocytes, 20% medium lymphocytes, 25% large lymphocytes and the Ziehl-Neelsen smear was negative. The culture for Mycobacterium spp. was negative. Suspecting a BCG arthritis and cystitis we started empiric antituberculous (antiTB) and glucocorticoid therapy. A week after admission Serratia marcescens was identified in one blood culture out of three collected, so we added ertapenem for 14 days. Rheumatological examination raised suspicion of an autoimmune illness, but all specific blood tests were negative. Despite that, the rheumatologist added sulfasalazine, considering that even BCG arthritis can associate an autoimmune disorder. After 2 months of antiTB, glucocorticoid and sulfasalazine treatment the evolution was favorable, with remission of arthritis and fever.

Resistance profile of Staphylococcus aureus strains isolated from patients treated in a tertiary care hospital in Romania

Results We examined 149 strains of S. aureus, 44.9% from cutaneous wound infections, 31.2% from blood cultures, 8.4% from sputum samples and 15.3% from other infection sites. Of the total number of strains identified, 55.7% were resistant to methicillin, 35.1% were resistant to clindamycin (D-test results are presented separately), 30.9% were resistant to levofloxacin, 18.7% were resistant to rifampin and smaller percentages were identified for resistance to other drugs. Surprisingly, resistance was also identified to drugs that are not used in clinical practice in Romania, such as daptomycin (6.8%) or fusidic acid (4.8%), suggesting a possible international circulation of S. aureus strains, probably through means of nasal or axillary carriage. We excluded a mechanism of daptomycin non-susceptibility through thickened bacterial cell walls in strains of vancomycin-intermediate S. aureus, as all strains were susceptible to vancomycin.

Nasopharyngeal microbiota evaluation in three cohorts of children in the Romanian pediatric population

Methods We performed a screening study for nasopharyngeal carriage of Staphylococcus spp. in immunocompetent children aged 7-10 years old, attending a community school in central Bucharest (group 1), and in two groups of immunosuppressed children: children with hemato-oncologic diseases (lymphoma/leukemia) admitted to the Fundeni Clinical Institute, Bucharest (ages 2-10 years, group 2), and institutionalized children with vertically transmitted HIV infection, from the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest (ages 1-10 years, group 3).

Assessment of bacteriophage activity against local strains of Enterococcus and Pseudomonas in Romania.

Methods In this study we used a bacteriophage testing kit containing 4 types of Georgian products: PYO, INTESTI (Eliava BioPreparations, Tbilisi) and PHAGYO, PHAGESTI (JSC “Biochimpharm”, Tbilisi) to test the strains of Pseudomonas spp. and Enterococcus spp. isolated and stored from patients treated in the Adults II ward of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Romania during April 2013 – July 2014.

HIV viral load assessment in multiple sanctuaries – case presentation

Case report We present the case of a 57 year-old male patient, diagnosed with HIV infection for 14 years, and polyexperienced to antiretroviral (ARV) therapy (history of over 15 past ARV regimens). Early on in the evolution of HIV infection, the patient developed arterial hypertension, cardiomyopathy, 80% bi-carotid atheromatosis, and neurocognitive impairment. The patient also developed dyslipidemia and significant lipodystrophy correlated with the use of first generation protease inhibitors. The impressive size of the buffalo hump led to impaired respiratory movements and trachea compression (identified through bronchoscopy, which had been indicated for the differential diagnosis of lung cavities; unfortunately because of the tracheal compression, bronchoscopy could not be performed). A surgical intervention for lipodystrophy had to be deferred because of the inability to maintain a stable ARV regimen, with undetectable viral loads. In Sep 2010 we managed to establish a stable ARV regimen, with boosted darunavir plus etravirine plus raltegravir. Plasma viral load decreased slowly, but it fluctuated, and it was only in Jan 2013 that the patient reached stable undetectable levels, and at this point, his CD4 cell count had increased to 321 cells/cmm. In early 2014, after the patient had been virally suppressed for approximately one year, he was referred to a plastic surgery clinic, where he underwent successful lipoaspiration of 12 kg of adipose tissue from the buffalo hump, along with reconstruction of adipose facial features. Thus, the surgical procedure had a double role, both esthetic and functional, leading to improved pulmonary ventilation and a better tolerability to performing daily activities. Given the history of difficulty maintaining a suppressed viral load in his patient, we assessed the potential HIV compartmentalization: after 6 months of consistently undetectable viremia, we performed sperm viral load (undetectable) and CSF viral load (undetectable), and after one year of viral suppression, we performed a viral load from the adipose tissue (results still in process).

Bi-compartmental evaluation of bacterial prints in infectious diseases – study hypothesis

Background PCR-based tools for detection of bacterial infections can considerably shorten the timespan from patient admission to initiation of targeted antibiotherapy. As culture-based methods are operator-sensitive and yield lower rates of identification in longer timespans, dependent on speciesspecific growth rates, there is a need for new techniques leading to rapid identification of the pathogenic agent and its antimicrobial susceptibility profile. PLEX-ID (Abbott Molecular Inc, Des Plaines, USA) ensures bacterial identification in a matter of hours, directly from clinical specimens, through PCR amplification and electrospray ionization-mass spectrometry.

Early serum screening for hepatocellular-carcinoma in patients with hepatitis

Background Chronic hepatitis is an important problem worldwide, associating high morbidity and mortality, and hepatocellular-carcinoma is one of its most severe complications. Multiple studies have tried to identify biomarkers that would allow an earlier detection of hepatocellularcarcinoma (HCC), compared to imagistic exams. Such biomarkers are represented by alpha-fetoprotein (AFP), des-gcarboxy prothrombin (DPC), and the lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3).

A cohort study in the assessment of liver fibrosis and markers of disease progression in hepatitis B and D coinfection

Results We assessed data from 64 patients (of which 27 were males 42%) with a median age of 54±14 (range: 23 to 64 years). The median fibrosis was 0.44±0.23 and the median necroinflammatory activity was 0.54±0.24. The median FIB-4 score was 1.89±3.23 at the second visit versus 1.26±2.07 at the third visit. The median APRI score was 1.18±1.67 at the second visit compared to 1.79 ±2.53 at the third visit (p=0.05, 95%CI: 0.0389, 0.43681). Regression analysis showed a correlation between FibroTest (considered the gold standard in this study, in the absence of histology data from liver biopsy), FIB-4 (p=0.43) and APRI (p=0.011).

Recurrent infective endocarditis due to probable biofilm formation on cardiac stimulator probe

Background The global increase in antibiotic resistance and the high number of implant-associated infections have rendered antibiotics ineffective in certain cases. So it’s time for a new therapy. Bacteriophages are obligatory intracellular parasites of bacterial cells and bacteria can be infected by bacteriophages. They have specificity of infection, due to the presence of specific receptors on the bacterium surface.

Dialysis peritonitis in a patient with chronic kidney disease and multiple comorbidities

Background Patients with peritoneal catheters are at risk for developing infections with germs with altered antibiotic sensitivity, being classified as Carmeli 3 due to repeated invasive contact with the hospital system. A cloudy peritoneal fluid is oftentimes a sentinel sign of infection and medical and surgical management are generally required to clear infection and prevent subsequent reoccurrences.