Clinical and diagnostic manifestations of tickborne mixed infection in combination with COVID-19

The coexistence of various pathogens inside the patient's body is one of the poorly studied and current issues. The aim of the study is to identify the relationship between the indicators of complex laboratory diagnostics and the clinical manifestations of a mixed disease during subsequent infection with the SARS-CoV-2 virus using the example of a case of chronic encephalitis-borreliosis infection. Seven blood serum samples were collected from the patient over the course of a year. For the etiological verification of the causative agents of TBE, Lyme disease and COVID-19, the methods of ELISA and PCR diagnostics were used. The patient was diagnosed with Lyme disease on the basis of the detection of IgG antibodies to Borrelia 5 months after the onset of the disease, since she denied the tick bite. In the clinical picture, there was an articular syndrome and erythema migrans. Later, IgG antibodies to the TBEV were found in the blood. Throughout the study, IgM antibodies to Borrelia were not detected. The exacerbation of Lyme disease could be judged by the clinical manifestations of this disease and by the growth of specific IgG antibodies. A feature of this case was that during an exacerbation of the Lyme disease, an infection with the SARS-CoV-2 virus occurred. Treatment (umifenovir, hydroxychloroquine, azithromycin, ceftriaxone) was prescribed, which improved the condition of the underlying disease, decreased joint pain, decreased IgG levels to borrelia. However, during this period, serological markers of TBEV appear: antigen, IgM antibodies, and the titer of IgG antibodies increases. Most likely, this was facilitated by the switching of the immune system to the SARS-CoV-2 virus, with the simultaneous suppression of borrelia with antibiotics and the appointment of hydroxychloroquine, which has an immunosuppressive effect. Despite the activation of the virus, clinical manifestations of TBE were not observed in the patient, which is most likely associated with infection with a weakly virulent TBEV strain. The further course of tick-borne infections revealed the dominant influence of B. burgdorferi in relation to TBEV. Laboratory studies have shown that suppression of the activity of the borreliosis process by etiotropic treatment subsequently led to the activation of the persistent TBEV.

[Time course of changes in cytokines (IFN-γ, IFN-α, IL-18, TNF-α) in the treatment of moderate influenza A (H1N1) pdm09 (2013-2016) with oseltamivir (Tamiflu) and umifenovir (Arbidol) alone and in combination with Kagocel]

AIM

To assess correlation of cytokines levels and therapy regimes a relationship of the time course of changes in the cytokines IFN-γ, IFN-α, IL-18, and TNF-α to the treatment option for influenza A (H1N1) pdm09 with umifenovir (Arbidol) 800 mg/day for 5 days (n=50); oseltamivir (Tamiflu) 150 mg/day for 5 days (n=50); umifenovir (Arbidol) 800 mg/day for 5 days in combination with Kagocel 72 mg/day for 2 days.; 36 mg/day for 2 days (n=50); oseltamivir (Tamiflu) (150 mg/day for 5 days) in combination with Kagocel 72 mg/day for 2 days; 36 mg/day for 2 days (n=50). A comparison group consisted of 30 healthy volunteers.

MATERIAL AND METHODS

The state of immunologic reactivity was assessed twice: at admission of the patients to an infectious disease clinic (at 1-3 disease days) and in the early convalescent period (at 7-8 disease days): venous blood samples were collected to determine the concentrations of IFN-γ, IFN-α, IL-18, and TNF-α by a solid-phase enzyme immunoassay.

RESULTS

All the patients in the acute phase of influenza A showed a statistically significant increase in the levels of IFN-γ, IFN-α, and IL-18 as compared with the control group. The groups receiving monotherapy in the early convalescent period had a decrease in the IFN-γ, IFN-α, and IL-18 concentrations that could be compensated by the combined use of the immunomodulator Kagocel. No statistically significant changes in the levels of TNF-α were found in the patients of all the groups, but the groups receiving monotherapy exhibited its lower concentrations in the convalescence period.

CONCLUSION

The combination of etiotropic antiviral drugs with Kagocel enhances the efficiency of antiviral therapy. Monitoring of antiviral cytokines during the treatment of influenza A is a convenient tool to verify the efficiency of antiviral therapy and needs to be more widely introduced into medical practice.

The Effects of Residual Pump Blood on Patient Plasma Free Haemoglobin Levels Post Cardiac Surgery

At the end of cardiopulmonary bypass, there are invariably several hundred millilitres of residual pump blood in the reservoir, which can either be re-transfused or discarded. The objective of this prospective observational study was to investigate the quality of the residual pump blood, focusing on plasma free haemoglobin (pfHb) and blood cell counts. Fifty-one consecutive patients were included in the study. Forty-nine units of residual pump blood and 58 units of transfused red blood cell (RBC) concentrates were analysed. The mean preoperative pfHb of the patients was 0.057 ± 0.062 g/l, which increased gradually to 0.55 ± 0.36 g/l on arrival in the intensive care unit postoperatively. On the first postoperative day, the mean pfHb had returned to within the normal range. Our data showed that haemoglobin, haematocrit, and erythrocyte counts of residual pump blood were approximately 40% of the values in standardised RBC concentrates. Plasma free haemoglobin was significantly higher in residual pump blood compared to RBC concentrates, and nearly twice as high as the pfHb in patient blood samples taken contemporaneously. Our findings indicate that residual pump blood pfHb levels are markedly higher compared to patients' blood and RBC concentrates, but that its administration does not significantly increase patients' pfHb levels.

Psoriasis and porphyria cutanea tarda, associated with chronic hepatitis C in HIV-infected patients (clinical observation)

The continued growth of HIV-infected patients is associated on the one hand, with increase of life expectancy because of antiretroviral therapy, and the other - with high incidence of new cases of HIV-infection. It is important to remember that almost every HIV-infected patient has concomitant disease. The presence of comorbidity increases days of hospitalization, disability, impedes rehabilitation and leads to polypharmacy. Moreover, polypharmacy, particularly in HIV-patients, contributes to a sharp increase of adverse local and systemic side effects of drugs. This article presents the clinical examples of skin diseases in patients with HIV-infection.

Oxy-RVAD: rescue in pulmonary complications after LVAD implantation

Pulmonary complications after left ventricular assist device (LVAD) implantation seldom occur; however, if present, they may prove catastrophic. An Oxy-RVAD (oxygenator in right VAD circuit) is a lifesaving technique in such cases and allows freedom of introducing and removing an oxygenator into the RVAD circuit without opening the chest and competing with LVAD flow.

[Dengue fever in the Primorye Territory]

Eighteen cases of dengue fever were imported to the Primorye Territory in 2012-2013. The cases were related to visits to Thailand, Indonesia, and Vietnam. Of the 18 patients, 17 and 1 had classic and hemorrhagic dengue fever, respectively.

[A case of Chikungunya fever in the Primorye Territory]

The authors analyze a case of Chikungunya fever imported to Vladivostok. The disease was severe and resulted in disability in a female patient for more than 6 months. There were difficulties in its differential diagnosis with rheumatic diseases.

Surgical pleth index-guided remifentanil administration reduces remifentanil and propofol consumption and shortens recovery times in outpatient anaesthesia

BACKGROUND

The surgical pleth index (SPI) is an index based on changes in plethysmographic characteristics that correlate with the balance between the sympathetic and parasympathetic nervous system. It has been proposed as a measure of the balance between nociception and anti-nociception. The goal of this study was to test whether it could be used to titrate remifentanil in day-case anaesthesia.

METHODS

A total of 170 outpatients were given total i.v. anaesthesia with propofol and remifentanil. The patients were randomized to have the remifentanil dose either adjusted according to the SPI (SPI group) or to clinical parameters (control group). The propofol dose was adjusted according to entropy in both groups. The consumption of anaesthetic drugs, recovery times, and complications were compared.

RESULTS

The mean [standard deviation (SD)] remifentanil and propofol infusion rates in the SPI and control groups were 0.06 (0.04) vs 0.08 (0.05) µg kg(-1) min(-1) and 6.0 (2.1) vs 7.5 (2.2) mg kg(-1) h(-1), respectively (both P<0.05). The mean (SD) times to eye opening were -0.08 (4.4) and 3.5 (4.3) min and to extubation were 1.2 (4.4) and 4.4 (4.5) min in the SPI and control groups, respectively (both P<0.05). There was no difference between the groups with regard to satisfaction with the anaesthetic or intensity of postoperative pain. No patient reported intraoperative awareness.

CONCLUSIONS

Adjusting the remifentanil dosage according to the SPI in outpatient anaesthesia reduced the consumption of both remifentanil and propofol and resulted in faster recovery.

[Physicians' knowledge on cancer pain therapy : Comparison of palliative care and prehospital emergency physicians in training]

BACKGROUND

Palliative care needs a high level of expertise. In particular, there are some potential difficulties in the treatment of patients with the symptom cancer pain (for example lack of education). In Germany, various physicians are involved in cancer pain treatment but in general palliative care patients are treated by a physician who is educated in palliative medicine. In special circumstances prehospital emergency physicians and other physicians are involved in therapy decisions in palliative care patients as well. The authors surveyed different groups of physicians in Germany about their specific knowledge of cancer pain management.

MATERIAL AND METHODS

A self-designed, standardized questionnaire (50 items) was given to palliative physicians in training (PP). The survey asked prospectively for knowledge on the World Health Organization (WHO) step ladder of cancer pain therapy. The results were retrolectively compared with an earlier investigation with the same background (emergency physicians in training EP).

RESULTS

There was a 99.5% response rate with a total of 654 respondents (PP 185, EP 469) and 461 (70.5%) of the respondents had knowledge of the WHO step ladder for the treatment of cancer pain [PP 164/185 (88.6%), EP 297/469 (63.3%), PP versus EP p < 0.001)]. The correct numbers of therapeutic levels were known by 361/461 participants [PP 151/164 (92.1%), EP 210/297 (70.7%), p < 0.001].The EPs with a professional experience less than 5 years answered statistically significantly more questions correctly (p = 0.004). Concerning the defined parameters knowledge and professional experience, there was no statistically significant difference in the group of PP.

CONCLUSIONS

The results of this study verified that the highest knowledge scores were achieved by PPs and overall, the knowledge scores showed an improvement in comparison to previous investigations. In recent years there seems to have been an improvement in education on pain treatment,for example during medical school. Whether this also leads to an improvement of patient care and the relevance of these data for the clinical practice needs to be investigated in further studies.

Recurrent strokes under anticoagulation therapy: Sticky platelet syndrome combined with a patent foramen ovale

The sticky platelet syndrome (SPS) is a congenital disorder characterized by platelet hyperaggregability to epinephrine and/or adenosine diphosphate; this predisposes affected individuals to acute myocardial infarction, ischemic optic neuropathy, recurrent venous thromboembolism, and transient ischemic cerebral attacks and strokes. Here, we describe an unusual case with recurrent cerebrovascular accidents due to SPS, in the presence of a patent foramen ovale (PFO). We report an unusual case of a 56-year-old female patient with a PFO, who suffered from recurrent strokes despite long-term medication with clopidogrel for SPS. The patient underwent successful transcatheter closure of the PFO, and, in addition, she has been placed on low-dose acetylsalicylic acid. After 18-month follow-up, she demonstrated an intact atrial septum without any vegetations on the percutaneous device until today. She has had no further thromboembolic events.

[Pandemic influenza in Russia: specific features of clinical course and the absence of early etiotropic therapy as a risk factor of severe forms of the disease]

AIM

To assess efficacy and safety of ingavirin in the treatment of the flu caused by pandemic virus of flu A (H1N1) sw1 in hospitalized patients compared with oseltamivir.

MATERIAL AND METHODS

A population-based comparative multicenter trial included 194 patients with verified diagnosis of the flu aged 18-60 years with marked clinical symptoms, body temperature over 38 degrees C and duration of the disease 48 hours maximum. The patients were randomized into 2 groups: group 1 (n=152) received ingavirin (90 mg once a day), group 2 received oseltamivir (n=42) in a dose 150 mg twice a day. Duration of the course was 5 days.

RESULTS

Ingavirin and oseltamivir normalized body temperature within treatment hours 24-36 if therapy was initiated in the first disease hours 27.0 +/- 10.0 and 31.9 +/- 10.4. Mean duration of the fever for ingavirin was 35.1 +/- 14.5 hours, for oseltamivir--26.3 +/- 13.0 hours (p < 0.817). The antiviral medicines significantly reduced duration of intoxication (head ache, weakness), catarrhal symptoms (cough, tracheitis, rhinitis), rate of complication vs. patients untreated with antivirus drugs (n=30).

CONCLUSION

The results of the treatment show safety and efficacy of ingavirin in uncomplicated flu caused by pandemic virus of flu A (H1N1) sw1 in inpatients. Early etiotropic therapy is a basic treatment policy able to reduce the number of severe complications and lethality.

Extracorporeal life support in pediatric patients with congenital heart diseases: outcome of a single centre

AIM

In pediatric patients with congenital heart disease low cardiac output (LCO) is the principal complication after corrective heart surgery. In LCO refractory to all therapeutic options, mechanical circulatory support is the final method to keep these patients alive. In this present study the authors reviewed the outcome of pediatric patients who required mechanical circulatory support after corrective surgery with extracorporeal membrane oxygenation or ventricle assisted devices (VAD).

METHODS

A retrospective single centre consecutive cohort study was carried out in children who required different mechanical circulatory support indicated by postcardiotomy low output syndrome between 1991 and 2004. A total of 20 patients received extracorporeal life support. The indications for surgery were: 12 transposition of great arteries, 1 Bland-White-Garland syndrome, 3 tetralogy of Fallot, 1 hypoplasia of aortic arch, 1 total anomalous pulmonary vein connection, and 2 ventricle septum defect.

RESULTS

Mean age was 1.29 years. Mean duration of assist was 8.87 days. Seven patients out of 20 survived, six could be discharged after myocardial recovery from LCO and one could be discharged after successful heart transplantation. The overall mortality in patients with extracorporeal life support was 65%. The causes of death were multiorgan failure and bleeding in one case was a VAD related complication.

CONCLUSION

The use of extracorporeal life support (ECLS) shows a high mortality rate. However, ECLS can still help to keep some of those patients alive. Mechanical support devices are the ultimate chance to save time, to increase survival and to bridge the time until heart transplantation.

Clinical relevance of eNOS T-786C polymorphism for hospital mortality and morbidity in cardiac surgical patients

AIM

The endothelial nitric oxide (eNOS) gene T-786C polymorphism may influence as a genetic risk factor cardiovascular diseases and shows association with cardiovascular mortality. We hypothesized that this polymorphism may lead to increase mortality and morbidity after cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

In 500 patients who underwent cardiac surgery with CPB we investigated the eNOS T-786C polymorphism by DNA-sequencing. The patients were grouped according to their genotype in three groups (TT, TC, and CC).

RESULTS

The overall genotype distribution of T-786C polymorphism was TT=41.6%, TC=51.2%, and CC=7.2% respectively. The groups did not differ in age and gender. No significance was shown in preoperative risk factors, excluding peripheral disease (P=0.03). No difference was shown in Euroscore, APACHE II, and SAPS II. The usage of norepinephrine (P=0.03) and nitroglycerine (P=0.01) was significant higher in TC allele carrier. The mortality was quite uniform across elective and urgent subgroup. However, we found a significant difference concerning mortality and emergency cardiac procedures in homozygous C-allele carrier (P=0.014).

CONCLUSION

The present study demonstrates that this polymorphism contributes to a higher prevalence of postoperative mortality after emergency cardiac surgery. Thus, the eNOS T-786C polymorphism could serve as a possibility to differentiate high risk subgroups in heterogeneous population of individuals with cardiac diseases who need cardiac surgery with CPB.

Chronic heart failure induced by multiple sequential coronary microembolization in sheep

OBJECTIVE

Although a large variety of animal models for acute ischemia and acute heart failure exist, valuable models for studies on the effect of ventricular assist devices in chronic heart failure are scarce. We aimed to establish a stable and reproducible animal model of chronic heart failure in sheep.

METHODS

Sheep (n=8, 77 +/- 4 kg) were anesthesized and a 5F sheath was implanted into the left carotid artery. The left main coronary artery was catheterized under flouroscopic guidance and bolus injection of polysterol microspheres (90 microm, n=25.000) was performed. Microembolization (ME) was repeated up to three times in two to three week intervals until animals started to develop stable clinical signs of heart failure. Clinical and echocardiographic data were analyzed at baseline (base) and at three months (3 mo) after first ME. All animals were followed for 3 months after first microembolization and then sacrificed for histological examination. Another four healthy sheep (79+/-6 kg) served as control animals.

RESULTS

All animals developed clinical signs of heart failure as indicated by increased heart rate at rest (68+/-4 bpm (base) to 93 +/- 5 bpm (3 mo) (p<0.05)), increased respiratory rate at rest (28+/-5 (base) to 38 +/- 7 (3 mo) (p<0.05)) and increased body weight 77 +/- 2 kg to 81 +/- 2 kg (p<0.05) due to pleural effusion, peripheral edema and ascites. Echocardiographic evaluation revealed significantly an increase of left ventricular enddiastolic diameter from 46 +/- 3 mm (base) to 61 +/- 4 mm (3 mo) (p<0.05). Clinically and echocardiographically no significant changes were revealed in healthy control animals.

CONCLUSIONS

We conclude that multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with clinical and echocardiographical signs of chronic ischemic cardiomyopathy. The present model may be suitable in experimental work on heart failure and left ventricular assist devices, e.g. for studying the impact of mechanical unloading, mechanisms of recovery and reverse remodeling.

Histological changes in a model of chronic heart failure induced by multiple sequential coronary microembolization in sheep

AIM

Valuable models of chronic heart failure to perform histological studies are scarce. The authors aimed at investigating histological changes of the heart, lung, liver and kidneys in a stable and reproducible animal model of chronic heart failure in sheep.

METHODS

In 8 sheep (N.=8, 77+/-2 kg) chronic heart failure was induced by multiple sequential microembolization through bolus injection of polysterol microspheres (90 microm, N=25 000) into the left main coronary artery. Microembolization (ME) was repeated up to three times in two to three week intervals until animals started to develop stable signs of heart failure. Therefore, clinical and hemodynamic parameters were measured (Troponin T, heart and respiratory rate, cardiac output) after each embolization. Clinical examination was carried out by a veterinarian. All animals were followed for 3 months after first microembolization and then euthanized for histological examination. Histological data of the heart, lung, liver and the kidneys were analyzed in hematoxylin-eosin (HE) stains (10x, 25x, 100x) at baseline (control group) and at 3 months after first ME. Additionally preparations of heart tissue were stained with Picro-Sirius-Red (PSR) for planimetric quantification. A score from 0 to 4 according to Rassler et al. (2005) was used to assess the degree of lung injury.

RESULTS

All animals developed histological signs of heart failure as indicated by island-like, patchy fibrosis of the heart. Planimetric quantification (PSR stain) of the heart revealed a significant increase of the total amount of fibrosis from 8+/-2% (base) to 21+/-4% (3 months) (P<0.05), which was distributed homogeneously throughout the left ventricle (20+/-3% left ventricular [LV] anterior wall, 21+/-4% LV posterior wall, 20+/-4% septum). Histologic analysis of the lung demonstrated a moderate degree of interstitial edema and pronounced peribronchial processes of inflammation with beginning proliferation of fibrotic tissue. Liver tissue showed histological changes in terms of pericentral adiposis as sign of hypoxia in course of lacking perfusion. Signs of liver congestion could be detected histological in form of central-venous accumulation of erythrocytes and dissolution of liver tissue in proximity of the central veins. Kidney preparations illustrated loss of endothelial function and vascular occlusions, caused by microspheres, with decline of renal parenchyma particularly of the tubules.

CONCLUSION

Multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with histological signs of chronic ischemic cardiomyopathy and pathological changes of lung, liver and kidney, which can directly be coursed by chronic heart failure. Thus, the present model may be suitable in experimental work on heart failure and LV assist devices, e.g. for studying the impact of mechanical unloading, mechanisms of recovery and reverse remodeling.