Marija Santini

Acute Motor Axonal Neuropathy Associated with Pandemic H1N1 Influenza A Infection

BackgroundGuillain–Barre syndrome (GBS) is a well known entity that has many infectious agents reported as antecedent events. The spectrum of GBS includes acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor sensory axonal neuropathy (AMSAN), and some other variants like Miller-Fisher syndrome (MFS).MethodsPatient with AMAN variant of GBS after severe bilateral pneumonia and ARDS due to the novel pandemic H1N1 influenza A virus is presented.Results28-year-old white female was admitted to our Intensive Care Unit during the influenza pandemic because of severe ARDS due to bilateral pneumonia. The course of the disease was complicated with the new onset tetraplegia due to the AMAN variant of GBS. Treatment with plasma exchange was conducted and the patient had satisfactory recovery.ConclusionWe report a case of AMAN variant of GBS associated with proven H1N1 influenza A infection. This virus has not been reported previously as the agent of antecedent infection that induced this disorder. Risk factors for other causes of ICU neuromuscular weakness are usually present in the ICU patients and should not be the reason for reluctance in active quest for GBS. Once the diagnosis of GBS is established or suspected the treatment with plasma exchange or intravenous immune globulin is indicated.

Influenza A 2009 H1N1 encephalitis in adults with viral RNA in cerebrospinal fluid

Abstract We present 3 cases of influenza A 2009 H1N1 encephalitis occurring in adults, corroborated by viral genome detection in cerebrospinal fluid (CSF) and evidence of meningeal inflammation on brain histopathology. This paper emphasizes the possibility of viral detection in CSF and stresses the lack of an effective treatment for neurological manifestations of influenza.

Antibiotic resistance among nosocomial isolates in a Croatian intensive care unit--results of a twelve-year focal surveillance of nosocomial infections.

Abstract Continuous 12-year (1990-2001) focal surveillance of the antibiotic resistance among the most common nosocomial pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter sp. and Staphylococcus aureus) in 1325 Intensive Care Unit patients was performed. The surveillance period was divided in three 4-year time intervals (1990-1993, 1994-1997 and 1998-2001) and the prevalence of resistance was compared between intervals. Specimens included blood, urine and respiratory tract specimens. The incidence and trends of resistance to six antibiotics showed inconsistent results. Aminoglycoside resistance decreased among K. pneumoniae isolates (gentamicin 83%, 72.7% and 49.6%; amikacin 50.9%, 51.5% and 18.2%) and Acinetobacter sp. strains (amikacin 77%, 63.4% and 58.2%) but increased in P. aeruginosa (amikacin 27.5%, 63.3% and 44.1%). Overall, resistance to ceftazidime, ciprofloxacin, and imipenem increased but imipenem resistance is still low, particularly among Acinetobacter sp. Isolates (0, 2.1% and 1.5%). However, imipenem resistance increased among P. aeruginosa (10.2%, 31.6%, 22.1%). The prevalence of methicillin resistance was high but did not change during the surveillance period (82.3%, 78.3% and 82.2%). The present study suggests a complex picture of the development of antibiotic resistance in a single ICU. Significant changes occur over time but they are unpredictable and do not show identical tendencies for different species and antibiotics.

The importance of pathogens in sepsis: Staphylococcus aureus story

Abstract Different pathogens cause different outcomes for patients with sepsis. They influence intensive care unit (ICU) mortality, ICU length of stay (ICU LOS) and the need for mechanical ventilation (MV). We undertook a retrospective data-based analysis over a 6-y period. Seventy-eight patients with methicillin-sensitive Staphylococcus aureus (MSSA) and 74 patients with Escherichia coli (EC) sepsis were included in the study. ICU mortality for the MSSA group was 32 (41.0%) vs 26 (35.1%) for the EC group (p = 0.506; OR 1.28, 95% CI 0.67–2.48). There was no significant difference in ICU LOS (MSSA group: median 7.5, interquartile range (IQR) 4–14 days and EC: median 5, IQR 3–13.5 days; p = 0.214). Need for MV in the MSSA group was present in 45 (57.7%) patients vs 43 (58.1%) in the EC group. Univariate analysis did not show that MSSA was independently associated with ICU mortality (p = 0.506). Logistic regression analysis showed that after adjustment for APACHE II, the chance of ICU death doubled in the MSSA group (odds ratio 2.166; 95% confidence interval 1.004–4.858). The odds for ICU admission were 8 times higher in MSSA patients. MSSA sepsis should be considered as an independent factor for ICU mortality after adjustment for APACHE II.

Novel observations during extracorporeal membrane oxygenation in patients with ARDS due to the H1N1 pandemic influenza

ZusammenfassungWir berichten über neue Phänomene, die wir bei vier Patienten während des Einsatzes einer ECMO beobachtet haben. Die ECMO wurde wegen schwerem ARDS als Folge einer Pneumonie im Rahmen einer pandemischen Infektion mit H1N1 Influenza durchgeführt. Zwei Patienten hatten einen exzessiven Anstieg von konjugiertem Bilirubin im Serum. Die anderen zwei Patienten hatten einen unverhältnismäßigen Abfall des Gerinnungs Faktors IX. Die pathogenetischen Mechanismen und die klinische Bedeutung dieser beobachteten Phänomene werden diskutiert.SummaryWe report four patients with novel observations during extracorporeal membrane oxygenation support (ECMO). ECMO was initiated because of severe ARDS due to the primary H1N1 pandemic influenza pneumonia. Two patients had excessive conjugated hyperbilirubinemia and two had unproportional depletion of the coagulation factor IX. Pathogenetic mechanisms and clinical relevance of the noticed phenomena are discussed.

Decompressive craniectomy as salvage treatment in herpes simplex encephalitis: two case reports

Herpes simplex encephalitis is a rare disease with significant morbidity and mortality, although targeted therapy is widely available. This report presents two cases of herpes simplex encephalitis in previously healthy, young adults treated with acyclovir, who developed severe brain edema. Decompressive craniectomy prevented imminent brain herniation and a fatal outcome in both of these patients.

Long Term Outcomes of Acute Aseptic Encephalitis In Adults - a Single Center Study

Abstract Background Encephalitis is a heterogeneous syndrome associated with significant mortality and neurophysiological sequelae. The etiology is identified in only 20–50% of cases, and long-term outcomes of survivors are underinvestigated, especially in patients with unknown etiology. The aim of this study was to describe long-term outcomes of patients with aseptic encephalitis of various etiologies. Methods The study population consisted of a retrospectively identified cohort of consecutive adult patients diagnosed with viral and etiologically undiagnosed encephalitis during a 24-month period (2014-2015) at the University Hospital for Infectious Diseases Zagreb, Croatia. Clinical, laboratory data and short-term outcomes were collected from medical records, and long-term outcomes were assessed by telephone interviews and quantified through modified Rankin scores (mRS). Results A total of 90 patients were identified (57.7% female; 51.5 ± 17.4 years). Viral etiology was identified in 20 (22.2%) patients: herpes simplex virus (HSV-1, 8.9%), varicella-zoster virus (VZV, 6.7%), Tick-borne encephalitis (TBE, 4.4%) and enteroviruses (2.2%). Postinfectious meningoencephalitis was suspected in 14 (15.6%) patients, and 56 (62.2%) had unknown etiology. Elevated CSF WBC was present in 77 patients (mean of 169.3 ± 279.4/mm3) and all but 6 had elevated CSF proteins (1.23 ± 0.88 g/L). Convulsions occurred more frequently in HSV-1 (37.5%) and in unknown etiology group (15.7%). GOS<3 was noted in 50% of HSV, 33% of VZV, 25% of TBE and 24% of unknown group patients during hospitalization. Mechanical ventilation was necessary in 17.1% of patients with unknown and 23.5% with viral etiology for the mean duration of 1.8 ± 6.7 and 3.2 ± 6.3 days, respectively. The mean length of stay was 23.2 ± 18.5 days. In-hospital mortality was 7.8%. Among 64 survivors who were available for follow-up interviews (mean follow-up of 28.6 ± 6.8 months), 73.1% with unknown and 90.9% with viral etiology had favorable outcomes (mRS 0–1); 4 (6.25%) had moderate (mRS 3) and 3 (4.6%) had severe neuropsychological deficits (mRS 4-5). Conclusion Although the etiology of aseptic encephalitis is often unknown, long-term outcomes are favorable in the majority of patients. Disclosures All authors: No reported disclosures.

Early diagnosis of leptospirosis

A 25-years old man from Zagreb, Croatia, was admitted to the University Hospital for Infectious Diseases four days after the onset of symptoms such as fever, intense pain in the calves and anuria. The patient owned a rabbit and, before the onset of the disease, repaired some rubber pipes damaged by rodents. At admission, he had a severe clinical picture with fever, hypotension, jaundice, immobility, and pain in leg muscles. Treatment with ceftriaxone was initiated in combination with volume restitution. Renal failure soon ensued. Consequently continuous venovenous hemodiaphiltration therapy was performed. Due to acute respiratory distress syndrome, the patient was mechanically ventilated. The patient’s condition gradually improved and he recovered fully from multi-organ failure. Diagnosis was confirmed by a microscopic agglutination test (MAT) covering 15 leptospira serovars and real-time polymerase-chain reaction (PCR). The first serum sample taken on day 6 tested negative for leptospira, while PCR showed positive results for leptospiral DNA. The second serum sample taken on day 13 tested positive for serovar Canicola serogroup Canicola, serovar Patoc, serovar Grippotyphosa serogroup Grippotyphosa and serovar Tarassovi serogroup Tarassovi (titre 4000, 4000, 1000 and 2000, respectively), while PCR was negative. This report highlights the benefits of combining MAT and PCR methods in early diagnosis of leptospirosis.