Elena Dumea

Liver damage in HIV+HBV co-infected patients determined by transient elastography

In our country the prevalence of HIV-HBV co-infection in young infected patients, between 1985-1990, transmitted through nosocomial or vertical path is approximately 40%. We followed the prevalence and risk factors associated with liver damage in HIV+HBV infected patients. Longitudinal evaluation of liver fibrosis was carried out in the patients included in the study group, by transient elastography (TE). Several studies using non-invasive methods for the assessment of fibrosis have been performed in HIV infected patients, and in patients co-infected with hepatitis virus B, although up to now these methods have not been validated for this segment of the population. For statistical analysis, the TE results were designated to different stages of fibrosis in accordance with the previous recommendations. The predefined cut-off values were: F0-F1≤7.1 kPa, F2-F3>7.1 and ≤12.5 kPa and for cirrhosis (corresponding to F4) >12.5kPa. We included in the study 71 patients co-infected with HIV and hepatitis B. 71.85% of patients had minimal liver damage, 18.30% of them had moderate to severe fibrosis, 9.85% were F4. Patients were divided according to CD4 count into three groups: CD4 (0-200)/cmm, [200-500)/cmm, and >500 cells/cmm. By applying the ANOVA test we found significant differences between the 3 groups (p=0.037 500) [cells/cmm], p=0.033 400 copies/mL. For assessing the role of hepatitis virus B in liver disease severity in co-infected patients, patients were divided into two groups: HBV-DNA level≤ 2,000 IU/mL and >2,000 IU/mL. Since p=0.006 2,000 IU/mL), 95%CI (-4.642,-0.788). We confirm the role of HIV-induced immunosuppression in liver disease progression. As well we confirm the presence of more severe liver disease linked to hepatitis virus B replication.

Evaluation of anthropometric and virologic data in newborn from HIV positive mothers

Constanța used to be one of the most affected counties of Romania by HIV in children. Nowadays in Constanța there are an increasing number of HIV positive young women at fertile age who have babies. Even though there were implemented active measures for prevention of mother to child HIV transmission we still diagnose mothers with HIV after delivery. On the other hand HIV infection increases the risk of intrauterine growth restriction (IUGR) of newborn. The objectives of this study were to evaluate the proportion of children born from HIV positive women who presented IUGR; and to evaluate materno-fetal transmission rate of HIV in Constanța County. We performed a retrospective study on the relevant parameters in newborns and mothers: demographic data; CD4 count and HIV viral load in last trimester of pregnancy of mothers; HIV viral load in newborn. We analyzed anthropometric data of the newborn: weight, length, cranial circumference, and Apgar score. Statistical analysis was performed using SPSS version 19. Over a period of 6 years and 2 months, 135 newborn from 117 HIV+ mothers have been monitored. From all 135 children born from HIV positive mothers 5 were HIV positive. The median age in mothers was 23 and mean 23.08 (range: 17 to 39, SD=3.58). The mean Apgar score in newborns was 8.47 (range: 2 to 10, SD=1.202), and median 9. The mean birth weight in newborns was 2692 g (range: 1000 to 3900, SD=516.389), and median 2700 g. The proportion of children with birth weight less than 10th percentile was 58.05%. The mean length was 47.66 cm (range: 39 to 52, SD = 2.75), with a proportion of children below the 10th percentile of 27.4%. Infants who presented below the 10th percentile for weight and length were 23%. About 21.48% of infants were below the 10th percentile for weight, length and cranial circumference. Mean CD4 count in mothers in third trimester of pregnancy was 415.14 (range 27-1156), and median 397. 53.3% of mothers were with HIV viral load undetectable in the last trimester of pregnancy. In the studied period the mortality rate was 6.7% in children and 5.9% in mothers. The materno-fetal rate of HIV transmission was 3.7%. More than half (58.05%) of the infants born to HIV positive mothers were small for gestational age. 23% of infants were with IUGR and 23% of them presented symmetrical IUGR.

Lethal disseminated tuberculosis in patients under biological treatment – two clinical cases and a short review:

Tumour necrosis factor (TNF)-α inhibitors are highly used in Romania for the treatment of autoimmune disorders, such as rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases, and ankylosing spondylitis. Biological therapy using TNF-α inhibitors is very effective but is associated with an increased risk of opportunistic infections, including active tuberculosis. Here, two cases are presented of patients with RA and psoriasis under biological therapy who developed very aggressive forms of disseminated tuberculosis, with a rapid progression to death. The authors conclude that patients undergoing biological therapy require thorough evaluation prior to initiating treatment, followed by continuous and rigorous monitoring by a multidisciplinary team during biological treatment, particularly in countries with a high incidence of tuberculosis.

Multifactorial Analysis of Cardiovascular Risk Factors in a Group of Patients with Acute Myocardial Infarction

Abstract Background and Aims: Acute myocardial infarction is one of the main causes of mortality worldwide, atherosclerosis being the most common mechanism of coronary artery obstruction. Many cardiovascular (CV) risk factors are associated with these pathogenic processes. The aim of our study was to investigate a group of patients with ST-segment elevation acute myocardial infarction in terms of the prevalence of cardiovascular risk factors. Materials and Methods: We investigated 97 patients with acute myocardial infarction (AMI) and 30 persons without AMI (control group) for CV risk parameters (metabolic syndrome, diabetes, sedentary, dyslipidemia, glycosylated hemoglobin- HbA1c), and the risk of developing AMI. Results: We found statistically significant differences (p<0.05) for the patients with metabolic syndrome, diabetes, sedentary lifestyle, high level of total cholesterol, LDLc, HbA1c, low level of HDLc for the risk to develop AMI. Conclusion: This study emphasizes the need to implement measures of primary and secondary prevention, and carry out a strict control of cardiovascular risk factors as well as implicitly improve the therapeutic conduct.

Etiology of acute diarrhea in patients requiring hospitalization in Clinical Infectious Diseases Hospital - Constanța

Results In the study period 3,929 patients with AD (with 353 positive cases) presented to the Infectious Diseases Hospital out of which 2,550 children (with 301 positive cases) and 1,371 adults (with 52 positive cases). In children rotavirus enteritis ranked first in the etiology of infectious enteritis with a confirmed etiology of 62% over the entire period (186 cases) with a peak incidence in January-March – 78% of enteritis with infectious etiology confirmed (92 cases). Of bacterial causes of enteritis in children under 2 years, Klebsiella ranked first with 60% (32 cases), followed by enteropathogenic E. coli, with 25.9% (14 cases). The isolated strains of Klebsiella were 100% sensitive to imipenem, 92% sensitive to quinolones, 80% sensitive to ceftriaxone but only 33.3% sensitive to amoxicillin/clavulanic acid. In children over 2 years, the most frequently encountered bacteria was Salmonella spp. – 47.5% of bacterial enteritis (29 cases), followed by Shigella spp. – 26.2% (16 cases) and Campylobacter – 11.47% (7 cases). The most common cause of enteritis with confirmed infectious etiology in adults was Salmonella spp., with a percentage of 47.9% (23 cases), followed by Clostridium spp. with 29.1% (14 cases) and Shigella spp. with 16.6% (8 cases). The strains of Salmonella spp. that had been isolated from adults were 100% sensitive to: quinolones, cephalosporins, imipenem, gentamicin, but 26% (6 cases) were resistant to tetracycline.

Etiology of UTI – pathogens involved and their sensitivity to antibiotics

Methods At the Infectious Disease Hospital in Constanța, between January 2014 and June 2014, urine cultures were performed in patients presenting urinary tract infections. Urine was seeded by loops calibrated technique on Columbia agar with 5% sheep blood and Drigalski agar. To identify the germs we used latex agglutination kits for Gram-positive germs and API galleries (BioMerieux) for Gram-negative bacilli. Antibiotics susceptibility testing was performed with the help of Kirby-Bauer disc diffusion method.

Concordance between noninvasive assessments of fibrosis in patients with HIV/HIV+HBV infection.

Many studies used non-invasive methods to estimate the prevalence of significant fibrosis and its risk factors in patients with HIV infection. We evaluated the ability of APRI and FIB-4 score to differentiate between the different stages of fibrosis (no fibrosis/minimal fibrosis = F0-F1 and F2-F4 fibrosis moderate-severe/cirrhosis), taking as a reference, in the absence of liver biopsy, the hepatic fibrosis stratification by FibroScan. Group 1 was represented by 39 patients with HIV infection and group 2 by 71 patients with HIV/HBV coinfection. AUROC was used to calculate for each group and for each score the optimal value for identifying significant fibrosis. Then we determined the cut-off value that identifies significant fibrosis with maximum specificity. The Kappa score was then calculated for the concordance between methods. For HIV/HBV coinfected patients, to identify significant fibrosis score on tally Kappa classification for fibrosis by APRI versus FibroScan, Kappa=0.494, 95% CI (0.245, 0.742) on the identification of fibrosis (F0-F1 to F ≥2), for the FIB-4 Kappa=0.481, 95% CI (0.238, 0.725) for both the moderate concordance. Regarding the comparison of the two methods APRI and FIB-4 kappa=0.698, 95% CI (0.485, 0.910), significant concordance. For patients with HIV to identify significant fibrosis Kappa score tally on the classification of fibrosis by APRI versus FibroScan Kappa=0.217, 95% CI (-0.424, 0.858) on the identification of fibrosis (F0-F1 to F ≥2), for the FIB-4 Kappa=0.164, 95% CI (-0.451, 0.779) for both the correlation is reduced. Regarding the comparison of the two methods APRI and FIB-4 kappa=0.217, 95% CI (-0.424, 0.858), which confirms the low correlation. There is sufficient evidence that the tests used: APRI and FIB-4 have the ability to distinguish for both groups of patients between the two classes of fibrosis (F0-F1 to F≥2) meaning between patients with and without liver disease. Although for patients with HIV infection a low concordance was noted between non-invasive methods for the diagnosis of fibrosis, in coinfected patients it was moderate and these tests could be used as evaluation methods in the monitoring of liver injury especially when the results of these tests are concordant.

Opportunistic infections and immune reconstitution inflammatory syndrome (IRIS) in HIV infected patient – late presenter in cART era: case report

HIV-infected individuals are at high risk of developing numerous opportunistic infections. The severity of these infections may increase proportional to the immunosuppression degree. We must pay special attention to immune reconstitution inflammatory syndrome (IRIS) in order to prevent worsening symptoms and death. HIV coinfection is associated with high mortality rate despite effective antiretroviral therapy. We present the case of a 42 male patient who was diagnosed with AIDS and pulmonary tuberculosis in 2011 in our clinic. Our theme includes clinical, biological, immunological, virological evolution and therapeutics of this patient. He was a late-presenter patient with advanced immunodepression at baseline: low CD4 count, increased viral load in blood and cerebrospinal fluid. After a month of tuberculosis treatment, antiretroviral therapy was instituted according to guidelines. During one year the patient subsequently developed IRIS and, one by one, several opportunistic infections, including CNS involvement. Thus he presented: Cryptococcus neoformans meningoencephalitis resistant to fluconazole with multiple relapses, TB meningoencephalitis, severe form of CMV disease with encephalitis, demyelinating lesions, necrotic ulcerative stomatitis and esophagitis with HSV, systemic candidiasis, severe bacterial infections with multidrug-resistant germs. Diagnoses were based on the usual investigations, including molecular biology techniques (RT-PCR: Mycobacterium tuberculosis, JC virus, Cryptococcus neoformans), viral resistance testing, PLEX-ID, MRI. Viral PLEX-ID identified the presence of Epstein Barr virus in CSF at a high level. Opportunistic infections occurred imposed specific therapy and reconsideration of antiretroviral therapy with CNS penetration ARV (score Letendre). The patient was adherent to ARV therapy. The evolution was initially favorable under specific therapy with clinical, immunological and virological improvement. Unfortunately, about 10 months after diagnosis, the patient developed CNS lymphoma possibly in relationship with increased levels of Epstein Barr virus in CSF, having fatal outcome. The evolution of this case pointed out once again that in a patient with AIDS at the time of initiating ART, it should be considered the possibility of IRIS and future opportunistic infections, associated with a poor prognosis. Therefore it is important to detect persons with HIV infection in the early stages of the disease in order to obtain a favorable evolution.

Evaluation of hepatic fibrosis with noninvasive methods: transient elastography in HIV infected patients

Results The mean FibroScan score was 5.153 kPa, with a standard deviation (SD) of 1.493 kPa. There were 19 patients with CD4 counts between 200500 cells/cmm; in this group, the mean value of FibroScan was 5.378±1.415 kPa. In the 20 patients with CD4 count above 500 cells/cmm, the mean FibroScan score was 4.94±1.56 kPa. There were no statistically significant differences between groups regarding the CD4 count (p=0.36). In this study we did not select cases of patients with severe immunodepression (CD4 count below 200 cells/cmm). Regarding HIV viral load (VL), we split patients into two groups, above and below 400 copies/mL. There were 31 patients with VL less than 400 copies/mL; the mean FibroScan score was 5.161±1.633 kPa. There were 9 patients with VL more than 400 copies/mL, with a mean FibroScan score of 5.125±0.818 kPa. There were no statistically significant differences between groups regarding HIV VL (p=0.931). Conclusion In the studied patients there were no significant differences in terms of liver fibrosis evaluated by FibroScan. We included no patients with severe immunodepression and all patients received combined antiretroviral therapy. Noninvasive methods for the evaluation of liver fibrosis are less studied in HIV patients. Further extensive studies are necessary for such patients in order to evaluate cutoffs for assessing liver fibrosis and cirrhosis.