Sorin Rugină

Hospital-based surveillance to estimate the burden of rotavirus gastroenteritis in children below five years of age in Romania.

INTRODUCTION Rotavirus (RV) is a leading cause of acute gastroenteritis (AGE), affecting 95% of children below five years of age. METHODS In this prospective, multi-center study, children below five years of age who were hospitalized or those who visited the emergency room (ER) due to AGE or who developed AGE at least 48 hours after hospitalization (nosocomial infection) and had a RV-positive stool sample were included (n=1,222). RV-positive samples were genotyped by reverse-transcriptase polymerase chain reaction. RESULTS RV test results were available for 1,212 children (hospitalizations [n=677], ER visits [n=398] and nosocomial AGE cases [n=137]). Proportions of rotavirus gastroenteritis (RVGE) hospitalizations and ER visits were 51.70% (350/677; 95%CI: 47.86-55.52) and 36.18% (144/398; 95%CI: 31.45-41.12), respectively. Overall, 45.95% (494/1075) of all community-acquired AGE cases were due to RV. High numbers of RVGE cases were recorded between January and March. Most common genotypes were G9P[8] (34.27%) followed by G4P[8] (25.83%) and G1P[8] (23.02%). Of all community-acquired RVGE cases, the highest number of cases was observed in children aged 12-23 months. Median duration of hospitalization among RV-positive subjects was six days (range: 2-31 days). Incidence of nosocomial RVGE was 0.52 (95%CI: 0.45-0.60) cases per 1,000 child-days hospitalization. Median duration for additional hospitalization due to nosocomial RVGE was five days (range: 1-10). The highest burden of nosocomial RVGE was observed in children aged 12-23 months (42.34%, 58/137). Our findings confirm a high burden of acute RVGE disease in Romania and provide useful data to support the implementation of RV vaccination in Romania. TRIAL REGISTRATION NCT01253967.

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.

Disseminated tuberculosis in HIV-infected patients from the Regional HIV/AIDS Center Constanţa, Romania.

INTRODUCTION The purpose of our study was to evaluate clinical and pathological characteristics as well as treatment outcomes in HIV-infected patients with disseminated tuberculosis from the Regional HIV/AIDS Center Constanţa, Romania, and to determine associated risk factors. METHODS We analyzed HIV-infected adults diagnosed with disseminated tuberculosis (TB) over the past two years, monitored in the Regional HIV/AIDS Center Constanţa. RESULTS Out of a total number of 956 HIV-infected patients, 42 had been diagnosed with tuberculosis over the past two years (2011-2013) (4.39%) and 16 of them developed disseminated TB (38%). At the time of diagnosis, we recorded abnormal chest X-rays in 8 (50%), and positive sputum cultures in 4 (25%) of them. The median CD4 count was 40 cells/μL with a range of 5-85 cells/μL; HIV-RNA was detectable in all cases. Multidrug-resistant tuberculosis (MDR-TB) was identified in 6 cases. The outcome was unfavorable in 15 patients. CONCLUSION In our study, disseminated tuberculosis appeared to be a common pattern of evolution of HIV-TB co-infection (38%). Sputum smear positivity was low and chest X-ray images did not follow a typical pattern. HIV-TB co-infected patients with CD4 lymphocyte cell count <50 cells/μL were more likely to have disseminated TB. The severity of cases, proved by a high mortality rate, requires consideration of this diagnosis early in patients with advanced AIDS, even if laboratory investigations are not suggestive.

Nine-year follow-up of HIV-infected Romanian children and adolescents receiving lopinavir/ritonavir-containing highly active antiretroviral therapy

INTRODUCTION Many Romanian children were infected nosocomially with human immunodeficiency virus (HIV) in the late 1980s. The Romanian-American Childrens Center of Excellence in Constanţa continues to follow approximately 450 of these patients. In 2001, 414 of these patients were initiated on triple therapy including lopinavir/ritonavir. Data from this cohort treated through August 2006 were published in April 2007 demonstrating that the treatment was well tolerated, with 337 children (81%) remaining on therapy after a median duration of >4 years. The current article describes the results of continued analysis of this cohort through end 2010. The objective of the study was to determine the long-term clinical outcomes of children and adolescents commenced on antiretroviral therapy (ART) including lopinavir/ritonavir. METHODS Data were extracted retrospectively from the charts of the 336 patients remaining on lopinavir/ritonavir in August 2006. The following outcomes were analyzed: mortality, current patient status, viral load (VL), CD4 counts and reasons for discontinuation of lopinavir/ritonavir. RESULTS The median age at initiation of lopinavir/ritonavir was 14.0 years (range 5.4 to 20.0 years). The median time on lopinavir/ritonavir treatment was 7.5 years (interquartile range 5.7 to 8.6 years). Overall mortality was 13.5%. Of the original 414 patients started on lopinavir/ritonavir in 2001, 199 (48.1%) remained on this therapy at the end of 2010 and of these 63.8% had undetectable viral load. CONCLUSION Despite initial suboptimal ART, a significant proportion of patients subsequently treated with a lopinavir/ritonavir based regimen remained on this therapy for up to nine years.

Efficacy and safety of darunavir (Prezista(®)) with low-dose ritonavir and other antiretroviral medications in subtype F HIV-1 infected, treatment-experienced subjects in Romania: a post-authorization, open-label, one-cohort, non-interventional, prospective study.

INTRODUCTION The aim of the study was to assess the safety and efficacy of darunavir (Prezista(®)) used in subtype F human immunodeficiency virus - type 1 (HIV-1) infected, antiretroviral therapy (ART)-experienced patients in Romania in routine clinical practice. METHODS This was a post-authorization, open-label, one-cohort, non-interventional, prospective study conducted at multiple sites in Romania to assess efficacy (CD4 cell count, viral load, and treatment compliance) and safety ([serious] adverse events, clinical laboratory evaluation, and vital signs) of darunavir in combination with low-dose ritonavir (DRV/r) and other antiretroviral (ARV) medications in subtype F HIV-1 infected subjects in naturalistic settings. Seventy-eight subjects were recruited by 9 investigational sites and received 600/100 mg DRV/r twice daily. RESULTS Treatment with DRV/r administered with other ARV medications resulted in the expected, statistically relevant improvement of CD4 cell count and viral load in subjects eligible for such treatment. In addition, adherence to treatment was high and the treatment-emergent safety profile observed during this study was consistent with the established safety profile of darunavir. CONCLUSION DRV/r administered in combination with other ARV medications in subtype F HIV-1 infected subjects in naturalistic settings proved to be an effective and safe treatment in Romania. TRIAL REGISTRATION NCT01253967.

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.

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.

Screening for osteo-renal involvement in the Romanian HIV cohort

Background When assessing comorbidities in HIV-infected patients, the bone and the kidney represent important target organs that can potentially be affected by both virus and antivirals. Given the particular characteristics of the Romanian HIV cohort [1], most of the patients have experienced HIV infection in childhood and have received multiple therapeutic regimens since the advent of antiretroviral (ARV) therapy. Thus, the need to screen for osteo-renal impairment in these patients is high on the priority list [2].

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.