Vesna Turkulov

Infections and the elderly

Epidemiology Aging is a natural process and a part of our lives, but nowadays there is an increase in the number of persons aged 65 and over. Today infectious diseases are still responsible for one-third of all deaths in the world. The elderly population is most vulnerable to serious infections and at greatest risk for death and complications. Among geriatric population pneumonia and influenza are the fourth most common cause of death Vaccination One of the goals of preventive medicine is to reduce the rate of complications and mortality from infectious diseases by increasing immunization rates. Influenza and pneumococcal vaccines are indicated for persons aged 65 and over. Despite well-recognized benefit of such vaccination, less than 50% of eligible patients receive the vaccine each year. Infections Older persons generally have increased susceptibility to infections because of multiple risk factors and they are the most vulnerable population to nosocomial and health-care associated infections. Older persons may manifest infectious diseases atypically, with acute confusion or delirium which can lead into delay in diagnosis and therapy. It is important to know that the older present with delayed or poor response to antimicrobial therapy and high rates of adverse reactions to drugs, including antibiotics Conclusion As elderly population is rapidly growing, majority of patients with serious or life-threatening infections are old. Geriatric issues have not typically been a focus of training in infectious diseases, but we must become aware of and knowledgeable about special and unique aspects of infections in this population.

Leptospirosis distribution related to freshwater habitats in the Vojvodina region (Republic of Serbia)

The retrospective study (2002–2007) for human leptospirosis in Vojvodina was undertaken in order to describe the distribution of the disease in relation with some environmental factors. Regarding the presented results, the major detected number of leptospirosis cases concurs with stagnant waters, wetlands, fish pond areas and protected regions, which comprised the basis for mapping of the region in three risk zones: very high risk (incidence rate higher than 5.0), high risk (2.5–5.0) and medium risk of leptospirosis infection (1.0–2.5). During the investigated period, 97 cases were registered with an average of 13.85 cases per year: 2002, 32 cases; 2003, 7; 2004, 22; 2005, 16; 2006, 4 and 2007, 16. Out of these 97 cases only 5 were women. Serovars from 11 presumptive serogroups caused infection, with a predominance of Icterohaemorrhagiae and Bratislava, accounting for 72.72% of cases together. Icterohaemorrhagiae was the commonest infecting serogroup mostly connected with fish ponds. Case fatality ratio was 9.4%.

HIV-associated neurodegeneration and neuroimmunity: multivoxel MR spectroscopy study in drug-naïve and treated patients

AbstractObjectivesThe aim of this study was to test neurobiochemical changes in normal appearing brain tissue in HIV+ patients receiving and not receiving combined antiretroviral therapy (cART) and healthy controls, using multivoxel MR spectroscopy (mvMRS).MethodsWe performed long- and short-echo 3D mvMRS in 110 neuroasymptomatic subjects (32 HIV+ subjects on cART, 28 HIV+ therapy-naïve subjects and 50 healthy controls) on a 3T MR scanner, targeting frontal and parietal supracallosal subcortical and deep white matter and cingulate gyrus (NAA/Cr, Cho/Cr and mI/Cr ratios were analysed). The statistical value was set at p < 0.05.ResultsConsidering differences between HIV-infected and healthy subjects, there was a significant decrease in the NAA/Cr ratio in HIV+ subjects in all observed locations, an increase in mI/Cr levels in the anterior cingulate gyrus (ACG), and no significant differences in Cho/Cr ratios, except in ACG, where the increase showed trending towards significance in HIV+ patients. There were no significant differences between HIV+ patients on and without cART in all three ratios.ConclusionNeuronal loss and dysfunction affects the whole brain volume in HIV-infected patients. Unfortunately, cART appears to be ineffective in halting accelerated neurodegenerative process induced by HIV but is partially effective in preventing glial proliferation.Key Points• This is the first multivoxel human brain 3T MRS study in HIV. • All observed areas of the brain are affected by neurodegenerative process. • Cingulate gyrus and subcortical white matter are most vulnerable to HIV-induced neurodegeneration. • cART is effective in control of inflammation but ineffective in preventing neurodegeneration.

Proton Chemical Shift Imaging Study of the Combined Antiretroviral Therapy Impact on Neurometabolic Parameters in Chronic HIV Infection

BACKGROUND AND PURPOSE: The introduction of combination antiretroviral therapy has failed to reduce the high prevalence of mild forms of HIV-associated neurocognitive disorders. The aim of this study was to test the effect of combined antiretroviral therapy on brain metabolite ratios in chronic HIV infection by using proton chemical shift imaging. MATERIALS AND METHODS: We performed 2D chemical shift imaging in 91 subjects (31 HIV+ patients with chronic infection on combination antiretroviral therapy, 19 combination antiretroviral therapy–naïve HIV+ subjects with chronic infection, and 41 healthy controls), covering frontal and parietal subcortical white and cingulate gyrus gray matter, analyzing ratios of NAA/Cr and Cho/Cr on long-TE and mIns/Cr on short-TE MR spectroscopy. We correlated neurometabolic parameters with immunologic, clinical, data and combined antiretroviral therapy efficacy scores. RESULTS: There was a significant decrease in NAA/Cr (P < .05) in HIV-positive patients on and without combined antiretroviral therapy, compared with healthy controls in all locations. There were significant differences in Cho/Cr (P < .05) and mIns/Cr (P < .05) ratios between HIV+ patients on and without therapy, compared with healthy controls, but these differed in distribution. There were no significant differences in brain metabolite ratios between the 2 groups of chronically HIV-infected patients. The CNS penetration efficacy score showed weak positive correlations only with Cho/Cr ratios in some locations. CONCLUSIONS: The impact of combined antiretroviral therapy on the process of neuronal loss and dysfunction in chronic HIV infection appears to be suboptimal in successful peripheral suppression of viral replication. Spectroscopic imaging might be a useful tool for monitoring the effects of different combined antiretroviral therapy regimens on brain metabolite ratios.

Fever of Unknown Origin in Elderly Patients

INTRODUCTION Causes of fever of unknown origin are different. It is considered that it can be caused with over 200 different clinical entities. Aetiological causes differ according to different categories of age. Febricity in the elderly is at most the result of autoimmune processes, malignancies, bacterial infections and vasculitis. OBJECTIVE The aim of this study was to determine the most common characteristics of fever, the most common laboratory, bacterial and viral tests and to analyze applied therapy in patients with unknown febrile state, and to affirm final diagnosis in elderly patients, as well as younger than 65 years old, and to define outcome of disease in both groups of patients. METHODS Research comprised 100 patients who had been treated at the Infectious Disease Clinic of the Clinical Centre of Vojvodina in Novi Sad, during a three-year period, and in whom fever of unknown origin had been diagnosed. Patients were divided into two homogenous groups of 50 people. The first one (S) consisted of patients older than 65 years, and the second, control group (K) was constituted of patients younger than the age of 65. All of them were chosen by random sample method. RESULTS Average results of standard laboratory parameters of infection were obtained, such as erythrocyte sedimentation rate (ESR), fibrinogen, CRP, and especially leukocyte, and those were significantly higher in the group of elderly patients. The cause had not been found in 10% of elderly patient group, and in the younger group, not even in the third of patients. Among known causative agents dominant were infections, usually of respiratory and urinary tract, in both tested groups. Even 28% of the elderly had sepsis, and 10% endocarditis. Malignant diseases were more frequent in group of the elderly patients, and immune i.e. systematic disorders were evenly noticed in both groups of patients. CONCLUSION Despite advanced studies in medicine, and existence of modern diagnostic procedures, fever of unknown origin is still today differential diagnostic problem.

May Patients with Alcohol Liver Disease Benefit from Herbal Medicines

Alcoholism is currently listed as the third leading cause of death. Chronic alcohol consumption brings serious medical complications like gastrointestinal, cardiovascular, musculoskeletal, respiratory system disorders. Liver can be seriously damage by alcohol misuse. Alcoholic Liver Disease (ALD) is the first important warning sign of alcohol abuse. Since effective therapies for ALD are still limited, natural products in the treatment of ALD become very important. In this regard, there have been done very few clinical trials with poor results. Silymarin, glycyrrhizin, garlic show some promising results in ALD patients while the in vivo and in vitro studies with green tee, quercetin and curcumin indicate positive effect on patients with ALD.

Clinical characteristics of infectious spondylodiscitis.

Spondylodiscitis represents an inflammatory process, localized in the vertebrae body and in the intervertebral discs. The goals of this research were to identify subjective complaints, clinical findings, and laboratory characteristics in patients with spondylodiscitis, as well as to establish the importance of magnetic resonance imaging in diagnosing this disease. The data of 40 patients treated at the Clinic for Infectious diseases of the Clinical Center of Vojvodina from 2003 till 2007 were reviewed. Majority of the patients had low back pain (90%). Fever was present in 37.5% of patients (chi2 = 2.5; p > 0.05). Laboratory parameters of inflammation were higher than normal in most of the patients before the treatment. Diagnosis of spondylodiscitis was made using MRI in 97.5% of the patients. Keeping in mind unspecific subjective complaints and clinical findings in patients with spondylodiscitis, a health professional should always suspect spondylodiscitis when back pain occurs, in order to diagnose and treat this severe disease as early as possible. Magnetic resonance imaging is the most advantageous method in diagnosing spondylodiscitis.

First report of imported case of dengue fever in Republic of Serbia

we would like to follow up on a recent paper Valerio et al. Authors stated in conclusion that the incidence of dengue and chikungunya is steadily increasing in the North Metropolitan area of Barcelona, a region densely colonized by Aedes albopictus, at the entire expense of imported cases (especially visiting friends and relatives travelers) [1]. We report, for the first time, a viraemic dengue primary infection imported from an endemic country (Havana, Cuba) to Republic of Serbia. The patient was admitted to the hospital at early post-febrile period (stage II). Dengue fever was caused by DENV-3 with clinical presentation of febrile illness without progress to more severe and potentially fatal disease involving haemorrhage or shock. The 43 years old male patient with residence in Ka c (Municipality of Novi Sad), Serbia works as a travel guide. The disease started on the same day after return from Havana (2015-09-29), in the evening, by increased temperature, chills and muscle aches. During his last stay in Havana, Cuban health authorities informed him that prior to his stay 2 dengue cases were confirmed from the building he was residing. He was not vaccinated against Yellow fever or Tick-borne encephalitis and his anamnesis did not have previous dengue fever infections. Serological analysis by indirect immunofluorescence test (“Flavivirus profile 2”, Euroimmune, Germany) revealed Dengue 3 virus e specific IgM antibodies. The sample had a borderline result for Dengue 3 IgG antibodies and a negative result for IgM and IgG antibodies against the West Nile virus, Japanese encephalitis virus, and Yellow fever virus. The case was confirmed as Dengue 3 virus infection by real-time RT PCR, using “DENV-1-4-RT-PCR” primers and probe kit, provided by CDC (Atlanta, USA). Presence of IgM with borderline result of IgG antibodies accompanied with RT-PCR positive result demonstrated that this DENV-3 infection was primary.

Prediction of brain atrophy using three drug scores in neuroasymptomatic HIV-infected patients with controlled viremia

BACKGROUND Despite potent antiretroviral therapy, HIV still causes brain damage. Better penetration into the CNS and efficient elimination of monocyte/macrophages reservoirs are two main characteristics of an antiretroviral drug that could prevent brain damage. The aim of our study was to assess efficacy of three antiretroviral drug scores to predict brain atrophy in HIV-infected patients. METHODS A cross sectional study consisting of 56 HIV-infected patients with controlled viremia, who had no clinically evident neurocognitive impairment. All patients had MRI of the head. A typical T2 transversal slice was analyzed and ventricles-brain ratio (VBr) as an overall brain atrophy index was calculated. Three antiretroviral drug scores were used and correlated with VBr: 2008 and 2010 CNS penetration effectiveness scores (ΣCPE2008 and ΣCPE2010) and the recently established monocyte efficacy (ΣME) score. A p-value <0.05 was considered significant. RESULTS ΣCPE2010 was significantly associated with VBr in both univariate (r=-0.285, p=0.033) and multivariate (β=-0.299, p=0.016) regression models, while ΣCPE2008 was not (r=-0.141, p=0.300 and β=-0.156, p=0.214). ΣME was associated with VBr in multivariate model only (r=-0.297, p=0.111 and β=-0.406, p=0.029). Age and reported duration of HIV infection were also significant predictors of overall brain atrophy in multivariate regression models. CONCLUSIONS Although based on similar type of research, ΣCPE2010 is a superior drug score compared to ΣCPE2008. ΣME is an efficient drug score in determining brain damage. Both ΣCPE2010 and ΣME scores should be taken into account in preventive strategies of brain atrophy and neurocognitive impairment in HIV-infected patients.

[Fever of unknown origin--a case report of brucellar discitis].

INTRODUCTION Febrile episodes of unknown origin lasting for two weeks require detailed investigation by various medical specialists. Fever of unknown origin is most commonly caused by infections, malignancy, colagenosis and in 5-10% of cases, despite detailed diagnostic assessmnet, the cause remains unknown. In cases of fever of unknown origin, the diagnostic procedures are difficult and complex. CASE REPORT This is a case report of brucellar discitis in a female patient treated at the Clinic of Endocrinology, Diabetes and Metabolic Diseases with a diagnosis of fever of unknown origin. Her laboratory findings revealed high erythrocyte sedimentation rate, anemia and high gamma globulin fractions. The patient underwent radiology examination and a suspicion of infection was defined, which was later confirmed by additional tests. CONCLUSION Despite the fact that the diagnostic investigations of patients with fever of unknown origin are complex and time consuming, detection of the cause is of utmost importance and it is a prerequisite for successful therapy.