Olgica Gajovic

[Lyme borreliosis--diagnostic difficulties in interpreting serological results].

INTRODUCTION Lyme borreliosis is a multi-systemic disease caused by spirochete Borrelia burgdorferi sensu lato. The specific response is influenced by phenotypic characteristics of Borrelia, different antigen structure, their different geographic distribution, and the patients capability to react to the infection. The immune response to Borrelia burgdorferi sensu lato develops relatively late, whereas in some patients it never develops. The immune response in the early phase of Lyme borreliosis is very similar to the one of healthy population. DIAGNOSIS OF BORRELIA Clinical manifestation, detailed anamnesis and epidemiological data are crucial for making the diagnosis. The majority of patients in the late phase of Lyme borreliosis have IgG antibody response, which could be followed by IgM also throughout this period of time. The number of serologically positive findings increases with the duration of the infection. Specific borrelial antigens can be detected by a Western blot test. In patients with neuroborreliosis, antibodies could be synthesized only intrathecally. IgG and IgM antibody response can persist for many years after the treatment. There is no positive serological test, which could be the indicator of the disease activity on its own; even if it demonstrates high antibody titre. If there are no clinical signs of Lyme borreliosis, the diagnosis of Lyme borreliosis should be primarily based on clinical findings, and serological results should be used only to confirm but not to make the diagnosis of Lyme borreliosis. Specific antibodies from the IgM class can be proved in about 50% of patients, 2 to 4 weeks after the onset of primary infection, but an early administration of the antibiotics can postpone or inhibit that response. INTERPRETATION OF SEROLOGICAL RESULTS When interpreting the serological test results with high level of sensitivity and specificity used for making diagnosis of Lyme borreliosis, it is necessary to take into consideration the seroprevalence in a certain region. In the population with a low prevalence of the disease, the tests will have a low positive predicative value, i.e. the probability of indicating the real disease will be lower. According to the recommendations given by the Centre for Disease Control in North America, all extreme and positive results of EA and IFA are to be confirmed by a Western blot test. DIAGNOSTIC PROBLEMS The main problem in making diagnosis of Lyme borreliosis is underestimation and overrating of the diagnosis. Not a single positive serologic test is the indicator of the disease activity on its own, regardless of the antibodies titre level, when clear clinical signs are scarce.

Hospital infections in a neurological intensive care unit: incidence, causative agents and risk factors

INTRODUCTION Hospital infections (HIs), which are frequently associated with hospital treatment, increase morbidity, mortality and treatment costs. The aim of this study was to establish the incidence of HIs in a neurological intensive care unit (nICU), and to determine the most prevalent causative agents and risk factors for HIs. METHODOLOGY A cross-sectional study with nested case-control design was conducted between 1 July 2009 and 30 June 2010 at an 18-bed neurological intensive care unit at the Clinical Center Kragujevac, Serbia. RESULTS In total, 537 patients were enrolled in the study, with 6,549 patient-days. There were 89 patients with 101 HIs. The incidence of patients with HIs was 16.57%, and incidence of HIs was 18.81%, while density of HIs was 15.42 per 1,000 patient-days. The most frequent anatomical sites of HIs were urinary tract (73.27%), blood (10.89%), and skin and soft tissues (10.89%). The following risk factors were identified: co-morbidity (OR=3.9; 95% CI=1.9-7.9), surgical intervention in the last 30 days (OR=5.6; 95% CI=1.5-20.4), urinary bladder catheterization longer than seven days (OR=3.8; 95% CI=1.8-8.2), value of Glasgow coma scale ≤ 9 (OR=3.7; 95% CI=1-6.9), and longer hospital stay (OR=1.1; 95% CI=1.1-1.2). CONCLUSIONS Hospitalization in an nICU bears high risk of HIs, especially of urinary tract infections caused by Gram-negative bacteria, in patients with longer hospital stay or co-morbidities, and in those who have had surgical interventions or prolonged use of a urinary bladder catheter. Special attention should be paid to these patients to prevent HIs.

[Hemorrhagic fever with renal syndrome during pregnancy: case report].

INTRODUCTION Hemorrhagic fever with renal syndrome (HFWRS) is an acute infectious disease with abrupt onset, high fever, renal failure and frequent hemorragies. HFWRS during the pregnancy has relatively low occurrence, with only few described cases mostly in the region of the former Soviet Union. Although, according to the data from the literature, the disease is less severe during the pregnancy, the eclampsy, stillbirth and fetal infection were also described. MATERIAL AND METHODS During the summer period, June-September 2002 in the area of northeast Montenegro, and mainly among people whose job was connected with rural areas, the HFRS was observed more frequently. In that area during the stated period, 12 patients underwent treatment whose disease was confirmed by the IIF method at the Torlak Institute of Virology in Belgrade. Among the patients there were two pregnant women aged 23 and 29 (both in their second pregnancies), in the 23rd and 26th gestational week, respectively. The aim of this study is to present 2 case studies and to show the disease impact on fetal development. RESULTS The patients aged 23 and 29 yrs, were previously healthy women in their second pregnancies (23rd and 26th gestational week, respectively). The disease had typical beginning. The predictions made according to the laboratory abnormalities and the level of oliguria were that the disease would have a less severe course. Hemorrraghic syndrome was less prominent, and the laboratory analyses were normalized after 15 to 18 days. The monitoring of pregnancy during the disease period and after recovering showed no fetal suffering. The patients had PV delivery, in 39-th an 40-th, respectively. The newborns blood testing on Hantan viruses was done by ELISA method in Torlak Institute, Belgrade. Only the IgG antibodies (1/512), were detected, the IgM antibodies were not found. Two years later the tests were repeated, and showed negative results.

Risk factors for hospital infections caused by carbapanem-resistant Acinetobacter baumannii

INTRODUCTION Acinetobacter baumannii is one of major causative agents of severe, life-threatening hospital infections (HIs), especially in intensive care units (ICUs). Our aim was to discover the risk factors associated with the emergence of HIs caused by carbapenem-resistant Acinetobacter baumannii (CRAB), as well as those associated with death in patients who suffer from such infections. METHODOLOGY A prospective cohort study was conducted over a five-year period in the medical-surgical ICU of the Clinical Centre in Kragujevac, Serbia. The study group comprised patients who had HIs caused by CRAB, while the control group comprised patients infected with carbapenem-sensitive Acinetobacter baumannii. RESULTS In total, 137 patients developed HIs caused by Acinetobacter baumannii. The mean age of the patients was 59.65 ± 16.08 years, and 99 (72.26%) of them were males. In 95 patients (69.35%), the infection was caused by CRAB. There were six independent risk factors for CRAB infections: use of mechanical ventilation, previous stay in another department, stay in ICU for more than a month, and previous use of carbapenems, aminoglycosides, and metronidazole. Three independent risk factors were found for death in patients with HIs caused by CRAB: use of mechanical ventilation, previous stay in another department, and previous use of carbapenems. CONCLUSIONS The results of this study can be helpful when identifying patients with risk of HIs caused by CRAB and in planning preventive measures. Modification of known risk factors and appropriate institutional policy of antibiotic utilization are important measures that may decrease the incidence and mortality of such infections.

Life-Threatening Plasmodium Falciparum Malaria in Patient after Visiting Angola-Case Report

Abstract Malaria is a potentially life-threatening disease, especially when complicated by a septic shock. It is caused by infection of erythrocytes with protozoan parasites of the genus Plasmodium that are inoculated into the humans by a feeding female anopheline mosquito. Of the four Plasmodia species, infection with Plasmodium (P.) falciparum is often associated with different types of complications and significant mortality. Most imported cases of malaria are not in tourists but in immigrants and their children who have returned to the country of their family’s origin to visit friends and relatives (so-called VFR travelers) and have forgone chemoprophylaxis. We described a case of a 52 year old patient who came from Angola, an African country with endemic malaria before the occurrence of the first symptoms of the disease. The first symptoms were not recognized by the presence of nonspecific symptoms. Very soon the patient was gone under the hemodynamic unstability that eas followed by shock and high percentage parasitemia of 25%. A global health disorder was developed accompanied with hemodynamic instability and cerebral dysfunction. He performs pulmonary ventilation disorder and renal failure. Only data from social epidemiological survey of travel to the African country, was sufficient to cast doubt on malaria. The diagnosis was conducted using the standard method - peripheral blood smear. After turning antimalarial drugs, improvement of health status with complete recovery within 10 days was noticed. The only consequence of the disease is persistent hypertension that is sensitive to standard antihypertensive therapy.

Predisposing Factors Responsible for the Occurrence of Bacterial Purulent Meningoencephalitis

Bacterial purulent meningoencephalitis (BPME) is a life-threatening infectious disease caused by various pyogenic bacteria. The disease is defined as the inflammatory process of leptomeninges (visceral layer, pia mater and arachnoid membrane) and brain parenchyma with exudates in the subarachnoid space and surrounding brain structures. The aim of the study was to define the predisposing factors responsible for the occurrence of BPME, as well as the possible correlation between the presence of predisposing factors and patient demographic characteristics, etiology and outcome of the disease. This retrospective-prospective study included 90 patients with BPME confirmed by clinical, neuroradiological and laboratory findings. Multivariate logistic regression models were fitted to analyze the impact of the predisposing factors on the disease outcomes. Predisposing factors that were related to BPME were found in 61% of patients. Cranial trauma as the leading factor was recorded in 23.3% of patients, followed by previous neurological disease in 14.4% of patients, while 13 patients were exposed to previous chemotherapy or long-term corticosteroid therapy. Cardiovascular diseases were reported in 12.2% and diabetes in 7.8% of patients. The existence of cardiovascular diseases significantly influenced unfavorable outcome of the disease, i.e. ”deceased” in comparison to ”cured” (OR=8.418; 95% CI=1.007-76.270), independently of age and gender. None of the examined predisposing factors was significantly related to the ”recovered with sequels” outcome as compared with ”cured” outcome. Older age and presence of cardiovascular disease as a predisposing factor significantly increased the odds of the BPME unfavorable outcome ”deceased” as compared to ”cured” outcome.

Hospital-Acquired Pneumonia in Newborns with Birth Weight Less Than 1500 Grams: Risk Factors and Causes

Abstract Low birth weight newborns (≤1500 grams) are at a high risk of acquiring hospital infections due to the immaturity of the immune system, lack of efficient structural barriers, and an incomplete development of endogenous microbial flora. The aim of this study was to reveal the potential risk factors for hospital-acquired pneumonia in low birth weight newborns. This study was a prospective cohort design with a nested case-control study and was conducted between January 1st, 2012 and June 30th, 2015 at the Neonatology Department, Clinical Centre Kragujevac, Serbia. There were 1140 newborns hospitalized at the Neonatology Department for longer than 48 hours during the study period, and 169 of them (14.82%) weighed less than 1500 grams at birth. In total, 73 (43.19%) newborns with low birth weights developed HIs. The most prevalent HI was hospital pneumonia (n=64, 87.67%). Although univariate analyses identified many risk factors with a significant influence on the occurrence of hospital pneumonia, multivariate analysis identified only the following two independent risk factors for hospital pneumonia in newborns with birth weights below 1500 grams: mechanical ventilation (p=0.003, OR=68.893, 95% CI=4.285-1107.699) and longer hospitalization (p=0.003, OR=1.052, 95% CI=1.017-1.088). Almost all of the pathogens isolated from the patients with pneumonia were gram-negative bacteria (98.50%). More than half of all of the isolates were Acinetobacter spp (37.50%) and Enterobacter spp (18.75%). Our study showed that mechanical ventilation and prolonged hospitalization were significant risk factors for the development of hospital pneumonia in newborns with birth weights below 1500 grams.

Unusual Respiratory Manifestations of Ankylosing Spondylitis – A Case Report

Abstract A male patient, 54 years old, was initially admitted to the hospital because of fatigue he felt during the last month and swelling of the lower legs. Upon hospital admittance, gas exchange analysis showed global respiratory failure: pO2=6.1 kPa, pCO2=10.9 kPa, pH=7.35, A-a gradient = 1.0. Due to the existence of hypercapnia and decompensated respiratory acidosis, the patient was connected to a device for non-invasive mechanical ventilation. Reduced chest mobility was noticed, and the respiratory index value was decreased. Radiographs of the chest and thoracic and lumbo-sacral spine showed marked changes on the spine attributable to ankylosing spondylitis (AS). Radiographs of the sacroiliac joints showed reduced sacroiliac joint intraarticular space with signs of subchondral sclerosis. The diagnosis of AS was set on the basis of New York Criteria (bilateral sacroiliitis, grade 3) and clinical criteria (back pain, lumbar spine limitation and chest expansion limitation). HLA typing (HLA B27 +) confirmed the diagnosis of AS. Pulmonary function test proved severe restrictive syndrome. Polysomnography verified the existence of severe obstructive sleep apnoea (AHI =73). This was a patient with newly diagnosed AS, with consequent severe restrictive syndrome and global respiratory failure with severe obstructive sleep apnoea. Thee patient was discharged from the hospital with a NIV (global respiratory failure) device for home use during the night.

[Risk factors of nosocomial infections caused by piperacillin-tazobactam resistant Pseudomonas aeruginosa].

INTRODUCTION Pseudomonas aeruginosa is a common cause of serious infections in hospitalized patients and is associated with high rates of hospital morbidity and mortality. OBJECTIVE The aim of this study was to identify the risk factors of nosocomial infections caused by piperacillin-tazobactam-resistant P.aeruginosa (PT-RPA). METHODS A case-control study was conducted in the Clinical Centre Kragujevac from January 2010 to December 2011. RESULTS In the observed period, 79 (38.16%) patients had PT-RPA infections, while 128 (61.84%) patients had infections caused by piperacillin-tazobactam-sensitive P. aeruginosa (PT-SPA). Pneumonia was more frequently found in the PT-RPA group (55.70%) (p < 0.05), whereas urinary tract infections were more frequent in the group of patients with PT-SPA infections (26.56%) (p < 0.01). Multivariate analysis was used to identify an injury on admission (OR = 3.089; 95% CI = 1.438-6.635; p = 0.004), administration of imipenem (OR = 15.027; 95% CI = 1.778-127.021; p = 0.013), meropenem (OR = 2.618; 95% CI = 1.030-6.653; p = 0.043), ciprofloxacin (OR = 3.380; 95% CI = 1.412-8.090; p = 0.006), vancomycin (OR = 4.294; 95% CI = 1.477-12.479; p = 0.007), piperacillin-tazobactam (OR = 4.047; 95% CI = 1.395-11.742; p = 0.010) as independent risk factors associated with PT-RPA infection. CONCLUSION In hospitalized patients, the risk of PT-RPA infections is associated with previous administration of imipenem, meropenem, ciprofloxacin, vancomycin, piperacillin-tazobactam, and the presence of injury on admission.

The spectral analysis of motion: An "open field" activity test example

In this work we have described the new mathematical approach, with spectral analysis of the data to evaluate position and motion in the „„open field““ experiments. The aim of this work is to introduce several new parameters mathematically derived from experimental data by means of spectral analysis, and to quantitatively estimate the quality of the motion. Two original software packages (TRACKER and POSTPROC) were used for transforming a video data to a log file, suitable for further computational analysis, and to perform analysis from the log file. As an example, results obtained from the experiments with Wistar rats in the „open field“ test are included. The test group of animals was treated with diazepam. Our results demonstrate that all the calculated parameters, such as movement variability, acceleration and deceleration, were significantly lower in the test group compared to the control group. We believe that the application of parameters obtained by spectral analysis could be of great significance in assessing the locomotion impairment in any kind of motion. [Projekat Ministarstva nauke Republike Srbije, br. III41007 i br. ON174028]