Pavel Chalupa

Epidemiology and Clinical Features of Imported Dengue Fever in Europe: Sentinel Surveillance Data from TropNetEurop

Travelers have the potential both to acquire and to spread dengue virus infection. The incidence of dengue fever (DF) among European travelers certainly is underestimated, because few centers use standardized diagnostic procedures for febrile patients. In addition, DF is currently not reported in most European public health systems. Surveillance has commenced within the framework of a European Network on Imported Infectious Disease Surveillance (TropNetEurop) to gain information on the quantity and severity of cases of dengue imported into Europe. Descriptions of 294 patients with DF were analyzed for epidemiological information and clinical features. By far the most infections were imported from Asia, which suggests a high risk of DF for travelers to that region. Dengue hemorrhagic fever occurred in 7 patients (2.4%) all of whom recovered. Data reported by member sites of the TropNetEurop can contribute to understanding the epidemiology and clinical characteristics of imported DF.

Endemic Hepatitis E in the Czech Republic

BACKGROUND An increasing incidence of endemic hepatitis E (HE) has been reported in developed countries. Thus, an evaluation of the clinical characteristics of the disease and the utility of the current diagnostic methods is warranted. METHODS Fifty-one adult acute patients with HE hospitalized in a single center between the years 2009 and 2012 were evaluated. Serological and molecular techniques (detection of hepatitis E virus [HEV] RNA from stool and serum samples by quantitative reverse transcription polymerase chain reaction) with sequencing and phylogenetic analysis were used for diagnosis, and the clinical, laboratory, and epidemiological parameters of the patients were evaluated. RESULTS Forty-nine (96.1%) patients had acute endemic HE and 2 (3.9%) had an imported infection. In the cohort of patients with acute symptomatic HE (n = 47), men outnumbered women (40:7), the patients were in older middle age (mean, 60.57 years), and they had elevated median values of total bilirubin (6.67 mg/dL), alanine aminotransferase (2288.82 U/L), aspartate aminotransferase (1251.76 U/L), gamma-glutamyl transferase (360.53 U/L), and alkaline phosphatase (197.06 U/L). Serology was positive in 50 (98%) of the patients, and 1 case was diagnosed by polymerase chain reaction only. HEV RNA was detected in at least 1 specimen from 84.3% of the patients, and 28 of 29 tested isolates belonged to genotype 3. The eating of meat, innards, other home-prepared pork products, or the tasting of raw meat before cooking were the most frequently reported data (reported by 25 patients [49.0%]). CONCLUSIONS Large numbers of the endemic cases of HE were caused by HEV genotype 3, and the clinical characteristics of endemic HE were demonstrated.

Cytokines and Chemokines as Biomarkers of Community-Acquired Bacterial Infection

Routinely used biomarkers of bacterial etiology of infection, such as C-reactive protein and procalcitonin, have limited usefulness for evaluation of infections since their expression is enhanced by a number of different conditions. Therefore, several inflammatory cytokines and chemokines were analyzed with sera from patients hospitalized for moderate bacterial and viral infectious diseases. In total, 57 subjects were enrolled: 21 patients with community-acquired bacterial infections, 26 patients with viral infections, and 10 healthy subjects (control cohorts). The laboratory analyses were performed using Luminex technology, and the following molecules were examined: IL-1Ra, IL-2, IL-4, IL-6, IL-8, TNF-α, INF-γ, MIP-1β, and MCP-1. Bacterial etiology of infection was associated with significantly (P < 0.001) elevated serum concentrations of IL-1Ra, IL-2, IL-6, and TNF-α in comparison to levels observed in the sera of patients with viral infections. In the patients with bacterial infections, IL-1Ra and IL-8 demonstrated positive correlation with C-reactive protein, whereas, IL-1Ra, TNF-α, and MCP-1 correlated with procalcitonin. Furthermore, elevated levels of IL-1Ra, IL-6, and TNF-α decreased within 3 days of antibiotic therapy to levels observed in control subjects. The results show IL-1Ra as a potential useful biomarker of community-acquired bacterial infection.

Detection and Phylogenetic Characterization of Human Hepatitis E Virus Strains, Czech Republic

To determine the origin of hepatitis E virus in the Czech Republic, we analyzed patient clinical samples. Five isolates of genotypes 3e, 3f, and 3g were obtained. Their genetic relatedness with Czech strains from domestic pigs and wild boars and patient recollections suggest an autochthonous source likely linked to consumption of contaminated pork.

Jaundice complicated by an atypical form of Guillain-Barré syndrome

A 65-year-old male was admitted for a loss of strength he ad suddenly developed in his upper limbs and partially in his ower limbs, pain in both shoulders, subicterus, dark urine and levated serum values (total bilirubin (37 mol/L; range 0–20), LT (32.09 kat/L; range 0–0.8), AST (8.54 kat/L; range 0–0.65)). is cognition was normal, meningeal phenomena negative, and ranial nerves and skin sensation normal. A neurological examnation revealed paresis in all four extremities with prevalence n the left side with pronounced paresis of the plexus brachialis Duchenne-Erb). The reflexes of the upper extremities were arkedly weakened on both sides; mild proximal weakness was resent on the right, and moderate weakness was present on he left. The reflexes of the lower extremities were diminished nd there was a mild proximal weakness on the left side. The abinski sign was negative. The patient’s gait was very wide-

Heparin-binding protein as a biomarker of circulatory failure during severe infections: A report of three cases

Abstract We report 3 cases of disease – leptospirosis, tropical malaria and fulminant meningococcaemia – associated with high serum concentrations of heparin-binding protein (HBP) and haemodynamic instability. Furthermore, HBP kinetics were observed for the first 3 days in survivors and were correlated with improvement in clinical condition.

Phospholipase D-neutralization in serodiagnosis of Arcanobacterium haemolyticum and Corynebacterium pseudotuberculosis Infections

Phospholipase D (PLD) neutralization was used to examine sera of humans (n = 40) with a spontaneous infection by Arcanobacterium haemolyticum, sheep and goats (n = 76 and 79 respectively) with a spontaneous infection by Corynebacterium pseudotuberculosis, mice (n = 26) experimentally immunized with PLD from A. haemolyticum (PLD-A) and mice (n = 28) experimentally immunized with PLD from C. pseudotuberculosis (PLD-C). PLD-A and PLD-C were also used as neutralizing antigens. A positive result of neutralization was due to an inhibition of the haemolytic synergism with the equi factor from Rhodococcus equi. The titres of sera neutralizing the homologous PLD were always significantly higher than those neutralizing the heterologous PLD. The proportion of sera that were able to neutralize the homologous PLD in sheep, goats and mice immunized with PLD-A significantly exceeded the proportion of sera that neutralized the heterologous PLD. The antigenic properties of PLD-A and PLD-C were similar but not identical.

Favorable outcome of severe acute hepatitis B in a patient treated with antithrombin III and antiviral therapy.

To the Editor—A 47-year-old man was admitted to our institution with severe acute hepatitis B (SAHB). The patient had suffered deep venous thrombosis of both lower extremities 2 years previously, and 2 mutations (C677T and A1298C) in the gene for methylenetetrahydrofolate reductase (MTHFR) were detected. Moreover, the family history was positive for thrombophilic states—his mother had thrombosis of the central retinal vein. The clinical course demonstrated a gradual worsening, with encephalopathy and progression to fulminant hepatic failure occurring during the first week after admission. The bilirubin level rose to 314 mmol/ L (reference range, 0–20 mmol/L), and the alanine aminotransferase level rose to 87.5 mkat/L (reference range, 0–0.8 mkat/L). Moreover, a significant deterioration in coagulation parameters was apparent: the prothrombin time was 21.3 s (reference range, 10.9–15.3 s), the international normalized ratio was 1.85 (reference range, 0.80–1.20), the D-dimer level was 1380.0 ng/mL (reference range, 0–250 ng/mL), and the antithrombin III (AT III) level was 31% (reference range, 81%–130%). The initial therapy was aimed at combining antiviral treatment with improvement of the coagulation disorder. The patient received low-molecular-weight heparin, intravenous vitamin K, and 4 transfusion units (1000 mL) of fresh frozen plasma followed by 2000 IU of AT III concentrate and 100 mg of lamivudine (Zeffix) daily for viral suppression. This therapeutic approach led to a prompt correction of coagulopathy and to favorable clinical, biochemical, and virological responses over the next several days. Seroconversion to antibody against hepatitis B e antigen was recorded on the 11th day of lamivudine therapy; 5 weeks later, the biochemical and coagulation test results were normal, and hepatitis B surface antigen was undetectable. Lamivudine therapy was stopped after the second negative hepatitis B surface antigen test result, which was obtained 1 month later. SAHB is an intermediate state between acute hepatitis B with a moderate course and progression to fulminant hepatic failure. The following criteria for the diagnosis of SAHB have been proposed by Schmilovitz-Weiss et al [1]: (1) the presence of hepatic encephalopathy, (2) a serum bilirubin level 10.0 mg/dL ( 170 mmol/L), and (3) an international normalized ratio 1.6. The combination of 2 or more of these criteria is considered to be diagnostic. According to Tillmann et al [2], only 1 criterion is required for the diagnosis of SAHB: a prothrombin time 36% of normal (or either an international normalized ratio 12.0 or an absolute prothrombin time 23 s). The disturbances in blood coagulation are sequelae of the involvement of the coagulation and fibrinolysis pathways. Hemorrhage complicating the course of SAHB is due to reduced synthesis of clotting factors and inhibitors of coagulation and fibrinolysis. Less is known about AT III levels during the course of SAHB; AT III supplementation is therefore debatable. However, we chose more aggressive anticoagulation therapy for our patient with extremely low AT III levels and a potential thrombophilic state (ie, MTHFR deficiency and a history of deep venous thrombosis), and this therapy led to a rapid improvement in clinical status and laboratory parameters. It is worth noting that the fulminant course of SAHB is associated with an exaggerated immune response, which might be modulated by the strong anti-inflammatory effects of AT III [3]. Thus, the close monitoring of AT III levels and the combination of antiviral agents and AT III concentrate in the treatment of SAHB could be beneficial.

Effect of antiviral treatment of chronic hepatitis C on the frequency of regulatory T cells, T-cell activation, and serum levels of TGF-beta.

The aim was to analyze T‐regulatory cells (Tregs), activated CD8+ T cells, and transforming growth factor‐beta (TGF)‐β in hepatitis C patients. We enrolled 31 patients with chronic genotype 1 hepatitis C virus (HCV) infection, 30 seropositive persons with spontaneous HCV elimination, and 23 healthy volunteers. The patients were examined at the beginning of the interferon‐alpha (IFN‐α)‐based therapy (baseline) and at weeks 4 (W4) and 12 (W12) of the therapy. The percentage of Tregs and the expression of activation markers CD38 and HLA‐DR on CD8+ T cells were analyzed in the peripheral blood by flow cytometry. Serum levels of TGF‐β were measured in a multiplex assay using flow cytometry. The percentage of Tregs in patients was higher than in controls and seropositive persons. Similarly, the percentage of CD8+ T cells expressing CD38 and HLA‐DR was higher in patients compared with controls and seropositive persons. Chronic HCV infection is associated with elevated circulating Tregs and activated CD8+ T cells. During IFN‐α‐based therapy these cells gradually increase, whereas TGF‐β serum levels decrease.

Reply to Dr. Rashmi Ranjan Das on the question, “Should procalcitonin be used as a routine biomarker of bacterial infection?”

We thank Dr. Rashmi Ranjan Das for his relevant comments on our article [1]. The prospective design of our study was aimed at distinguishing bacterial and viral etiology of infection in order to support the use of empirical antibiotic therapy. We enrolled the most common infectious diseases that are associated with elevated inflammatory markers and characteristic clinical signs. We agree with Dr. Ranjan Das that the comparison of viral and bacterial infections of the same organ, such as the central nervous system (CNS), would have been a better approach, since we could have excluded the effects of local inflammatory response. However, bacterial meningitis (BM) is significantly less common than viral encephalitis or meningoencephalitis in the Czech Republic; the data are available from the Epidat (English version)—the database of the incidence of infectious diseases in the Czech Republic (http://www.szu.cz or also [2]). Furthermore, the majority of patients with BM are hospitalized in the intensive care unit (ICU) and our study was not designed to enroll ICU patients. Similarly, the incidence of viral pneumonia is much lower than that of community-acquired bronchopneumonia (CABP) in the Czech Republic. Nevertheless, we agree that some cases of viral pneumonia, such as 2009 H1N1 influenza A viral pneumonia, can be associated with elevated procalcitonin (PCT) serum levels and it would be interesting to find out whether this elevation represents fibroproduction associated with the development of acute respiratory distress syndrome (ARDS) or, rather, secondary bacterial infections [3]. It is well known that, in the majority of cases of CABP due to Mycoplasma and Chlamydophila spp., PCT serum levels are below 0.5 ng/mL [4]. However, three patients with pneumonia due to Chlamydophila pneumoniae in our study demonstrated PCT serum levels above 0.5 ng/mL (data not shown). This observation might evoke doubts as to whether the chlamydial pneumonia really exists [5]. Thus, we agree with Dr. Ranjan Das that advanced molecular diagnostics should be used in future studies, aimed at evaluating the potential biomarkers of infection. It is true that we did not comment on the significant difference of PCT serum levels between the groups of patients with CABP and uroinfection. Since the prevalent etiology of uroinfections is Gram-negative Enterobacteriaceae, the high serum levels detected in the patients with pyelonephritis or urosepsis were probably caused by a systemic effect of endotoxin. It was demonstrated that endotoxin is a strong inducer of PCT synthesis and release [6]. Also, some studies indicated significantly higher PCT serum levels in Gram-negative infections compared to Gram-positive infections [7]. In conclusion, we strongly support the implementation of serum PCT measurement in routine diagnostic panels used for the rapid clinical diagnosis of bacterial infections. Besides PCT, these panels should include not only the erythrocyte sedimentation rate (ESR), number of white blood cells (WBC), neutrophil and lymphocyte counts, and C-reactive protein (CRP), but they may also consist of the neutrophil to lymphocyte count ratio (NLCR), as has been recently suggested [8].