Irina Magdalena Dumitru

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Clostridium difficile colitis – a serious current problem

Background Clostridium difficile is currently considered a significant cause of nosocomial infection and is associated with increasing morbidity and mortality. The probability of colonization of hospitalized patients increases with the length of their hospital stay and depends on the local epidemiologic situation. The study aimed to evaluate the epidemiological, clinical and treatment features of Clostridium difficile colitis (CDC), and the relapse associated risk factors in the Infectious Diseases Clinic and Gastroenterology Clinic.

HLA class II alleles in Romanian patients with chronic hepatitis C

INTRODUCTION The objective of the study was to determine the association of host human leukocyte antigen (HLA) class II genotype DRB1 alleles with the response to interferon therapy, viral loads and extent of liver fibrosis in a group of Romanian patients diagnosed with chronic hepatitis C, with different clinical outcomes. Class II HLA genes, particularly the HLA-DRB1 and DQB1 genes, have been shown to have an important role in self-limiting or persistent viral infection, in different genetic populations. In chronic hepatitis C both susceptible and protective alleles have been described, influencing the development of autoimmunity and progression to cirrhosis and hepatocellular carcinoma. METHODS The study included 54 patients diagnosed with chronic hepatitis C, registered and monitored from January 2014 to January 2015 at the Clinical Hospital of Infectious Diseases, Constanţa, Romania. The selected patients were positive for anti-HCV antibodies and HCV-RNA, with screening laboratory results indicating HCV genotype 1b. The method used for the assignment of alleles at HLA-DRB1 and DQB1 loci was molecular genotyping, by the sequence specific oligonucleotide (SSO) hybridization method, and when required, by the sequence specific primers method (SSP). The presence of different alleles in patients has been analyzed for statistical significance. RESULTS The presence of HLA-DRB1*0301 had a high frequency (14.8%) in null-responders (NR) while alleles DRB1*0701 (11.1%), DRB1*11# (22.2%) and DRB1*0101 (16.7%) were prevalent in sustained virologic responders (SVR). No significant correlation was found between the presence of HLA-DRB1* alleles and viral loads or liver fibrosis with p values not statistically significant after the Bonferroni correction. CONCLUSION The presented data suggest that in this group of Romanian patients, certain HLA alleles influence the therapeutic response in HCV infection and genetic predisposition may play a role in hepatitis C virus infection in those patients.

Toxic Megacolon – A Three Case Presentation

Abstract Introduction: Toxic megacolon is a life-threatening disease and is one of the most serious complications of Clostridium difficile infection (CDI), usually needing prompt surgical intervention. Early diagnosis and adequate medical treatment are mandatory. Cases presentation: In the last two years, three Caucasian female patients have been diagnosed with toxic megacolon and treated in the Clinical Infectious Diseases Hospital, Constanta. All patients had been hospitalized for non-related conditions. The first patient was in chemotherapy for non-Hodgkin’s lymphoma, the second patient had undergone surgery for colon cancer, and the third patient had surgery for disc herniation. In all cases the toxin test (A+B) was positive and ribotype 027 was present. Abdominal CT examination, both native and after intravenous contrast, showed significant colon dilation, with marked thickening of the wall. Resolution of the condition did not occur using the standard treatment of metronidazole and oral vancomycin, therefore the therapy was altered in two cases using intracolonic administration of vancomycin and intravenous tigecycline. Conclusions: In these three cases of CDI, the risk factors for severe evolution were: concurrent malignancy, renal failure, obesity, and immune deficiencies. Ribotype 027, a marker for a virulent strain of CD, was found in all three cases complicated by toxic megacolon. The intracolonic administration of vancomycin, and intravenous tigecycline was successful when prior standard therapy had failed, and surgery was avoided.

Epidermodysplasia verruciformis in a HIV patient – case report

Epidermodysplasia verruciformis (EV) is a rare genodermatosis with an autosomal recessive pattern, characterized by an unique susceptibility to chronic cutaneous infections involving specific human papilloma virus (HPV) types in the genus β. Acquired EV, with clinical features similar to those in congenital EV, occurs only in immunocompromised patients, including those with HIV, lymphoma, transplant recipients and patients undergoing immunosuppressive therapy. Patients frequently present with verruca plana-like lesions (discrete or confluent, often red-brown papules) distributed on the extremities, usually dorsal hands, face and neck. Other characteristic clinical findings include flat scaly pinkish, red-brown or hypopigmented guttate macules or thin plaques, which are similar to pityriasis versicolor, especially if they develop on the trunk. EV is considered a premalignant condition and almost half of the patients develop in the fourth and fifth decades squamous cell carcinoma, most commonly on sun-exposed area. We report the case of a 26 years-old female patient with a history of HIV infection since the age of 6 years, receiving antiretroviral therapy, with a CD4 lymphocyte count of 545/μL and undetectable viral load, who presented for treatment of asymptomatic but cosmetically distressing skin lesions that had been present for almost 10 years. Dermatological examination revealed isolated flat and some confluent, reddish-brown discrete papules and erythematous macules, 2-7 mm in diameter, distributed on the dorsal hands, forearms and knees. Dermoscopy exhibited well circumscribed erythematous area with a whitish, scaly surface. Histopathology showed hyperkeratosis, slightly thickened epidermis, enlarged keratinocytes, some with basophilic and others with eosinophilic cytoplasm, hypertrophic nuclei with perinuclear halos, and intracytoplasmic keratohyalin granules. The diagnosis of EV verruca plana-like was confirmed. The patient was counseled about the disease and topical therapy with imiquimod cream was initiated, without improvement at one month follow-up. The patient is still on treatment and further therapeutic options are considered (cryotherapy, TCA peeling, electrotherapy and acitretin). EV in HIV is a rare condition, with only 30 cases reported in medical literature, and this patient is the first case of EV-HIV coinfection in our HIV department.

Immunological diagnosis of CMV infection in HIV-infected patients

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Clostridium Difficile Infection Complicated By Toxic Megacolon In Immunocompetent Patient

Abstract Toxic megacolon can be a form of severe clinical course of the infection with Clostridium difficile (ICD), life-threatening, requiring a particular course of treatment. Infection with Clostridium difficile in the Galati Infectious Disease Hospital presents rising number of cases, namely 172 cases in 2014, 271 cases in 2015 and 301 cases in 2016 with clinical evolutions with different severity degrees, including toxic megacolon and death. Among 744 patients with ICD in our clinic, since 1st January 2014 to 31 December 2016. The frequency of toxic megacolon (TM) was 0,537%, so: 3 toxic megacolon cases with favorable evolution with treatment with vancomycin and metronidazole and just one case whose evolution was aggravated under this therapy and evolved favorably under treatment with tigecycline. The work presents this last case of ICD occurred in a 69 years old, immunocompetent man with unknown concomitant chronic diseases which undergoes surgery for bilateral inguinal hernia and receives antibiotherapy with cephalosporin IIIrd generation during surgery and after 7 days develops medium degree ICD with score Atlas 3 and receives therapy with oral vancomycin. He presents clinical aggravation during this therapy with the occurrence of colon dilatation, ascites and right pleurisy at ultrasound and therapy associated with metronidazole is decided. Clinical aggravation continues in this combined therapy with defining the clinical, colonoscopy and tomography criteria for TM and is decided surgical monitoring and replacing antibiotherapy with tigecycline. Evolution is favorable with tigecycline without surgical intervention.

Efficacy Of Pegylated Interferon And Ribavirin Treatment In Coinfected HIV HCV Patients

Abstract The objectives of the study were to determine the efficacy of pegylated interferon alfa 2 b (PegINF) and ribavirin (RBV) treatment in co-infected HIV / HCV patients, to identify predictive factors associated with sustained viral response (SVR) in these patients. Out of the 956 HIV infected patients, 38 were HCVAb (4%) positive, 14 of which had undetectable HCV RNA, only 6 patients met the inclusion criteria. Screening failure was due to: liver cirrhosis Child Pugh B / C, hepatocellular carcinoma, pulmonary TB, thyroid dysfunction, CD4 <200 cells3, detectable HIV RNA and depressive syndrome. We initiated PegINF and RBV therapy for 48 weeks. SVR was achieved in 16.6% of cases (only one patient) and correlated with HCV RNA level, CD4 count, duration of HIV infection, CDC classification and liver fibrosis. In conclusion, our study group has a low prevalence of HIV / HCV co-infection (2.6%) with a large number of patients HCVAb positive but undetectable HCV RNA. Positive predictive factors for SVR were: low levels of HCV RNA, small duration of HIV infection, high levels of CD4, B1/B2 (CDC classification) and low degree of fibrosis.

HIV-1 Subtypes Circulating in Constanta

Abstract The HIV epidemic in Constanta describes a unique pattern in the world. It has outbreak in 1986, in the pediatric population and it is of a monoclonal aspect, being determined by the F1 subtype. The evolution of the epidemic has known different stages in time: it spreads to the adult population, the transmission pathway becomes predominantly sexual and the circulating viral strains become diversified. The study proposes the characterization of the circulating HIV-1 subtypes in Constanta from the beginning of the epidemic to the present. The results indicate that subtype F1 remains dominant in patients from Constanta, mainly due to cases coming from the pediatric cohort that have now reached adulthood and are generating secondary cases through sexual transmission. As subtype B strains appeared sporadically before 1999, the strains C and B appear systematically after that moment in time. In 2004 the first subtype A strains were isolated. The year 2007 is the one with the highest biodiversity: along with the dominant subtype F1, subtypes C, A, B, G were isolated and also the circulating recombinant forms CRF02_02, CRF06_cpx and CRF01_AE. Since 2008, the viral population has remained polymorphic, with a dynamic evolution.

The Management of Anemia in Patients with HCV Treated with DAA

Abstract Hepatitis C virus (HCV) infection affects approximately 180 million people worldwide, which accounts for roughly 2% - 3% of the world’s population. Complications arising from chronic HCV infection include the development of cirrhosis, end stage liver disease, and hepatocellular carcinoma (HCV). Objective: The study analyses management of anemia with patients in administrating DAA treatment (Telaprevir for 12 weeks). Material and method: We conducted a study on 24 patients who have concluded the DAA administration period, being now in the period of finalization of standard therapy. Results: Anemia was the most common adverse reaction,17 patients ( 70.8% ),mild anemia 5 patients (20.8%),medium anemia 8 patients( 47% ), severe anemia 4 patients (24% ). Hemoglobin levels were recorded during therapy, mild Hgb (10.0-10.9g/dl),medium Hgb (9.99-9.9 g/dl),severe Hgb (7.0-8.9 g/dl ), and analyzed the management of anemia in these patients. In the first 3 months of therapy ( DAA+PegINF and RBV ), doses of DAA not changed. Any doses of RBV were not modified in patients with mild anemia, in patients with moderate anemia patients received lower doses of RBV, while those with severe anemia patients received lower doses of RBV and red blood cells mass. Conclusions: Anemia was common adverse reaction in patients with DAA compared with previous results, only PegINF end RBV. Lowering the dose of RBV in the first 3 months, when patients received DAA did not affect SVR.