Violeta Molagic

Correlation between inflammatory biomarkers and metabolic disorders in HIV infected patients undergoing antiretroviral therapy

Correlation between inflammatory biomarkers and metabolic disorders in HIV infected patients undergoing antiretroviral therapy Raluca Mihăilescu, Victoria Aramă, Cătălin Tiliscan, Daniela Munteanu, Viorica Leoveanu, Mihaela Rădulescu, Adriana Hristea, Cristina Popescu, Ruxandra Moroti, Violeta Molagic, Raluca Năstase, Loredana Benea, Ana Maria Tudor, Mihai Lazăr, Anca-Ruxandra Negru, Irina Lăpădat, Ligia Ionescu, Mirela Cernat, Georgeta Jugănaru, Doina Cristea, Adriana Manea, Adrian Streinu-Cercel, Daniela Adriana Ion, Sorin Ștefan Aramă

Gut microbiota and its complex role. The experience of the National Institute for Infectious Diseases “Prof. Dr. Matei Balş” in fecal bacteriotherapy for Clostridium difficile infection

Gut microbiota and its complex role. The experience of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” in fecal bacteriotherapy for Clostridium difficile infection Cătălin Apostolescu, Ruxandra Moroti, Violeta Molagic, Valeriu Gheorghiță, Daniela Tălăpan, Mona Popoiu, Smaranda Botea, Alexandru Rafila, Marilena Palaghiță, Anca Budulac, Lavinia Ivănescu, Mirela Trifan, Gheorghiță Ciobanu, Adrian Streinu-Cercel

In the era of broad spectrum antibiotics, is ampicillin still an option?

Background In the era of broad spectrum antibiotics it is sometimes difficult to choose the best antimicrobial regimens. Because of misuse and abuse of antimicrobial usage, the level of resistance is increasing and sometimes we do not have treatment options. Infectious diseases specialists traditionally have the leadership role in optimal use of antimicrobials. Antimicrobial stewardship represents a worldwide accepted concept in order to preserve currently available antibiotics.

HIV-associated Burkitt lymphoma with bone marrow and cerebral invasion in a patient with history of Plasmodium falciparum infection

HIV infected patients are more likely to develop non-Hodgkin lymphoma (NHL). Burkitt lymphoma (BL) is a highly aggressive NHL, associated with immunosuppression, especially with HIV. According to WHO classification there are three clinical types of BL: endemic, sporadic and immunosuppression-associated. Sporadic lymphoma was described especially in children (40% of child lymphomas in USA and EU). Two cofactors seem to be associated with BL: Ebstein Barr virus (EBV) and Plasmodium falciparum (PF) infection. PF and EBV are well-known co-factors in the pathogenesis of BL, but the mechanisms of interaction remain unclear. We present a 51 year-old male, who developed lymphadenopathy, prolonged fever, weight loss, splenomegaly and seizure. The patient was admitted to a Hematology University Hospital. After lymph node biopsy he was diagnosed with BL. A specimen of bone marrow from the right iliac crest showed gross invasion by Burkitt tumor cells. The patient tested positive for HIV and he was referred to the National Institute of Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest. According to CDC Classification System for HIV Infection the patient had AIDS (C3 stage with a CD4 count of 39/cmm) and a high HIV viral load (500,262 copies/mL). The patient’s medical history revealed Plasmodium falciparum malaria 4 years ago, while he was living in South America. Epidemiological data revealed more than 200 sexual partners in the last two years. At admission to our hospital he had pancytopenia: white blood cells 1400/cmm, with 600 neutrophils and 600 lymphocytes, hemoglobin 9.6 g/dL and platelet count 25,000/cmm. The patient was tested for EBV infection and high titer of anti-VCA antibodies was found. ART was initiated with TDF-FTC-lopinavir/r with good virological outcome (after 6 weeks of therapy the viral load was 383 copies/mL). Cerebral MRI showed diffuse lymphomatous invasion. After 3 weeks of ART the patient was referred to Hematology Hospital where chemotherapy was started. Post-chemotherapy the pancytopenia was more severe: white blood cells – 200/cmm with CD4 count – 10/cmm, platelets – 15,000/cmm and hemoglobin – 7.9 g/dL. The BL response after chemotherapy was poor and the patient died two months after the diagnosis, despite the good virological outcome. We present a rare case of NHL in a HIV-infected patient, with multiple co-factors for BL: HIV infection, EBV infection and Plasmodium falciparum infection. The prognostic in AIDS depends on the comorbidities’ outcome.

Metabolic syndrome, insulin resistance and the risk of cardiovascular disease in HIV patients undergoing antiretroviral therapy

We enrolled 103 patients, including 60 males (58.3%) and 43 females (41.7%). The mean age was 32.3±13.3 years (range: 13-65 years). The median Framingham score was 1.2% (IQR=5.8%). Most patients (81.63%) had a low CVR (below 10%) and 18.37% had Framingham score values above 10%. MS and IR prevalences were 16.9% and 61.2%, respectively. CVR in the general population is primarily dependent on age. This observation was valid for our group: the median age was 24 years in people with low CVR, compared with 50 years for those with Framingham score above 10% (p=0.000). None of the antiretroviral drug classes significantly influenced CVR.

The multiple faces of tuberculosis in HIV infected patients – a continuous challenge

Tuberculosis (TB)/HIV co-infection represents a major problem in many regions of the world, including Romania. TB is a leading cause of death among people infected with HIV and HIV infection is the most important risk factor for progression from latent to active TB. TB can occur at any stage of HIV disease and its manifestations depend on the severity of immunosuppression. The proportion of extra-pulmonary tuberculosis in HIV infected patients has increased. Aim: to analyze the cases of pulmonary and extrapulmonary TB in HIV-seropositive patients monitored in Third Department of the “Matei Bals” Institute. We performed a retrospective analysis of all HIV infected patients monitored in our clinic from 2000 to 2014 in order to establish the location of TB, the diagnosis methods, the correlation with the immune status and the outcome. 122 patients were retrospectively analyzed; from them, 18 patients were diagnosed with certain, probable or possible TB infection (14.75%). Sex ratio in TB group was M:F=1.57:1 and mean age was 39.7 years old at the moment of TB diagnosis. TB occurs at a variable level of immunosuppression (CD4 count from 6 to 460/cmm) - 4 patients (22.2%) in stage 2 - CD4=200-500/cmm and 14 patients (77.8%) in stage 3 - CD4<200/cmm. Mean CD4 count in TB group was 113.23/cmm vs. 218.33 mean nadir CD4 count in non-TB group. Pleuro-pulmonary TB accounted for only 27.7% of all cases - one pleural effusion and 4 pulmonary TB. In most of cases, TB infection was extrapulmonary (72.3%): 5 cases of meningoencephalitis (27.7%), 3 cases of disseminated TB (16.66%), 2 cases of lymph node TB (11.11%) and 3 cases with unknown location (16.66%). TB was microbiologically confirmed in only 6 cases – 33.33%, 3 by blood culture, 2 by PCR (one from CSF and one from pleural effusion) and 1 by histopathologic exam (lymph node biopsy). In 9 cases TB was probable but without bacteriologic confirmation and in 3 cases TB was possible – prolonged fever with a good outcome under anti-TB medication. Quantiferon TB was performed in only 8 cases – in 6 cases was positive, in one case was negative and in one case was undetermined. Three patients died: one patient because of disseminated TB and two patients because of other HIV-related comorbidities. HIV infected patients developed especially extra-pulmonary TB infection. TB can occur in any stage of HIV infection. Microbiological diagnosis in TB is positive in a small number of cases.

Antiretroviral therapy adherence monitoring and its impact on immuno-virological outcome

One of the most important factors in achieving a good outcome is treatment adherence. Poor adherence to antiretroviral therapy (ART) leads to less viral suppression, permanent treatment resistance and increased costs. There are multiple causes of poor adherence: regimen complexity, side effects etc. Aim: to analyze ART adherence, risk factors for poor adherence and their impact on the outcome. We performed a one year survey (from January to December 2013) of HIV infected patients monitored in the Third Department of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”. The data (number of days covered by ART) was collected from patients’ files. We correlated the adherence with gender, regimen rank and complexity. Statistical analysis was made using EPI INFO 6. We retrospectively analyzed 111 patients who came in to our clinic monthly to pick-up their ART, 52 women (46.84%) and 59 men (53.16%) with a mean age of 43.5 years old. The adherence to ART was: 23 (20.62%) – 100% adherence, 36 (32.43%) – more than 96.7% adherence (less than 12 days without medication), 38 (34.23%) – 91.8% to 96.7% adherence (13-30 days without medication), 10 (9%) – 83.6% to 91.8% adherence (30-60 days without medication) and 4 (3.6%) with less than 83.6% adherence (more than 60 days without medication). The level of adherence was correlated with therapeutic failure: for 100% adherence – two failures (8.69%), for more than 96.7% adherence – no failure, for more than 91.8% adherence – 4 failures (11.1%), for more than 83.6% adherence – 2 failures (20%) and for less than 80% adherence – 3 failures (75%). Adherence below 91.8% was correlated with treatment failure: RR 5.65 (CI95% 1.99; 16.09, p=0.0007). We analyzed some possible risk factors for poor adherence: gender, regimen rank and complexity. Although 51.95% from the non-adherence group were women, the adherence wasn’t correlated with gender: RR 1.23 (CI95% 0.93; 1.62, p=0.16). A regimen rank higher than 1 was correlated with low adherence – 45.76% vs. 28.84% in the adherence vs. non-adherence group: RR 1.5 (CI95% 0.95; 2.38, p=0.07). The regimen containing protease inhibitors wasn’t correlated with low adherence: 33.9% vs. 30.8%, RR 1.08 (CI95% 0.71; 1.67, p=0.73). We emphasize the impact of therapy adherence on the outcome. A level of adherence below 91% was correlated with therapeutic failure. ART adherence wasn’t correlated with gender, PI regimen and rank regimen.

Clinical and epidemiologic features of community versus hospital-acquired Clostridium difficile infection

Methods We enrolled all CDI patients admitted to the Adults III department of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest, between January – July 2014. Stool culture, toxin EIA and Cepheid Gene Xpert C. difficile test were used for CDI diagnosis. The subjects were divided into two groups: CA-CDI patients (Group 1) and HA-CDI patients (Group 2). Our objective was to describe the clinical, epidemiologic features and outcome of CA-CDI compared to hospital-associated CDIs (HA-CDI) including the ATLAS bedside severity scoring system. Statistical analyses were performed using SPSS Statistics package v.17.

Short-term evaluation of immediately-treated patients with acute HIV infection, recently diagnosed in the National Institute for Infectious Diseases "Prof. Dr. Matei Balş", Bucharest, Romania

Methods All newly-diagnosed HIV-infected adults (>18 yo) in the last 18 months (01.2013-06.2014) in an infectious diseases hospital were considered. The including criteria for AHI group were: detectable HIV-RNA or positive antigen/antibody combination assays in the setting of a negative/indeterminate HIV Western blot. AHI group was classified accordingly to Fiebig stages and was further evaluated regarding CD4 count and viral load (VL) at diagnosis, at 3 and 6 months. ART initiation and the regimen were also registered.

Spondylodiscitis in Romania – between the risks of prolonged antimicrobial therapy and the poor access to neurosurgery

Background Spondylodiscitis defines both vertebral osteomyelitis and discitis. Two important etiologies are involved in the pathogenesis of spondylodiscitis: Mycobacterium tuberculosis (TB-S) and pyogenic bacteria such as Staphylococcus aureus (NTB-S). Diagnosis and treatment of spondylodiscitis are constantly delayed because the symptomatology is non-specific. There are controversial opinions regarding the optimal antimicrobial therapy duration. Aims: To overview the diagnosis and therapeutic difficulties in patients with spondylodiscitis.