Hepatitis E in a Portuguese cohort of human immunodeficiency virus positive patients: High seroprevalence but no chronic infections

Introduction

Hepatitis E virus (HEV) infection causes zoonotic hepatitis in Europe, with a higher risk of complications in immunocompromised hosts. HEV natural history in human immunodeficiency virus (HIV) positive patients is not fully understood, and its prevalence is unknown.

Objectives

To study the seroprevalence of HEV and prevalence of chronic HEV in HIV‐positive patients from Porto, Portugal.

Methods

We randomly selected patients from the cohort of HIV‐positive patients followed in our hospital. We performed an enzyme‐linked immunosorbent assay to search for immunoglobulin G for HEV. When the absorbance/cut‐off was inferior to 3.5, the test was repeated, and a confirmatory test executed in that sample. For reactive tests and for immunosuppressed patients (CD4 count < 200/mm³) with nonreactive test, a polymerase chain reaction (PCR) test was also performed.

Results

We included 299 patients. The mean age was 48 and 75.3% were men. Regarding HIV infection, the median follow‐up time was 10 years, the acquisition was mainly heterosexual contact, and 94% were on antiretroviral therapy. Seventy‐six patients (25.4%) had reactive immunoglobulin G (IgG) hepatitis E serology. Patients with a reactive test were older (statistically significant difference). Otherwise, there was no difference between groups concerning birthplace, rural residence, chronic viral hepatitis coinfection, or cirrhosis. Nadir and actual T_CD4+ lymphocyte counts did not differ significantly from patients with HEV reactive and nonreactive serology. Gamma‐glutamyl‐transferase (GGT) was higher in patients with reactive IgG HEV. All serum HEV PCR tests were negative.

Conclusions

Seroprevalence of HEV was 25.4% in HIV‐positive patients. Older age and higher GGT correlated to HEV reactive IgG test. No cases of current hepatitis E were found.

Infectious Risk Mitigation in Patients with Multiple Sclerosis under Disease-Modifying Therapies - the Experience of a Collaborative Neurology-Infectious Diseases Approach

Background

Multiple sclerosis treatment has changed in the last years with the emergence of new disease-modifying therapies (DMTs). Despite a better efficacy profile, these drugs raise concerns about infectious risk, which needs to be mitigated.

Objective

To analyze the results of a systematic collaborative approach between Neurology and Infectious Diseases (ID) Departments in the management of infectious risk and complications in MS patients treated with DMT.

Methods

Retrospective collection of MS patients’ demographic and clinical data from clinical records of MS and ID outpatient clinics (2011–2017).

Results

We included 149 patients: most had evidence of previous contact with Herpesviridae, and half of them were not immune to hepatitis A and B viruses (HAV and HBV). Vaccines for HAV, HBV, and Streptococcus pneumoniae were administered in 91%, 78%, and 88% of non-immune patients, respectively. JC virus serology monitoring prevented natalizumab (NTZ) initiation or prompted its switch in 34/122 patients. Forty patients had latent tuberculosis, in which 88% were treated. Infectious events occurred in 33 patients, mostly mild urinary, respiratory, and herpes virus group infections. Only three patients required inpatient care.

Conclusion

Facing the expansion of the new DMT, we highlight the benefits of an interdisciplinary approach for safer use of the chosen treatment.

Reactivation of latent infections in solid organ transplant recipients from sub-Saharan Africa: What should be remembered?

International migration from Sub-Saharan African countries to the European Union and the United States has significantly increased over the past decades. Although the vast majority of these immigrants are young and healthy people, a minority can be affected by chronic conditions eventually leading to solid organ transplantation (SOT). Importantly, these candidates can bear geographically restricted fungal and parasitic latent infections that can reactivate after the procedure. An appropriate evaluation before transplantation followed by treatment, whenever necessary, is essential to minimize such risk, as covered in the present review. In short, infection due to helminths (Schistosoma spp. and Strongyloides stercoralis) and intestinal protozoa (Entamoeba histolytica, Giardia lamblia or Cyclospora cayetanensis) can be diagnosed by multiple direct stool examination, serological assays and stool antigen testing. Leishmaniasis can be assessed by means of serology, followed by nucleic acid amplification testing (NAAT) if the former test is positive. Submicroscopic malaria should be ruled out by NAAT. Screening for Histoplasma spp. or Cryptococcus spp. is not routinely indicated. Consultation with an Infectious Diseases specialist is recommended in order to adjust preemptive treatment among Sub-Saharan African SOT candidates and recipients.

Panton-Valentine Leukocidin-Producing Staphylococcus aureus Infection: A Case Series

Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA) is associated with relapsing multifocal skin and soft tissue infections (SSTI), necrotizing pneumonia (NP) and severe musculoskeletal infections. Epidemiology is underknown and underdiagnosis is likely. Recent travel abroad, case clustering and relapsing disease are often reported. We reviewed all cases of PVL-SA infection diagnosed at our center, and found 21 cases over a 43-month period. Most patients were adult males, had relevant travel history, reported recurrent disease and presented with SSTI. Etiologic diagnosis took up to five years; meanwhile, 42% of patients had antibiotic treatments. Draining procedures were required in 43% of patients and intensive care support in 19%. All patients recovered. Methicillin-resistance prevalence was 24%. Only 2/13 decolonized patients had posterior relapsing SSTI, both with likely infected contacts. PVL-SA infection’s severity and impact are clear, even in small case series as ours. Physician awareness and active PVL-gene search are crucial for an adequate management.

Prospective study of blood viral load of Epstein-Barr virus, herpes virus type 6 and human parvovirus B19 in Crohn's disease: Does therapy matter?

BACKGROUND

The interplay between inflammatory bowel disease (IBD) and DNA viruses, such as Epstein-Barr (EBV), human parvovirus B19 (HPVB19) and human herpes type 6 (HHV6) is scarcely studied. The main aim of this prospective study is to screen for EBV, HSV6, and HPVB19 DNA viremia in adult patients with stable Crohn's disease (CD), correlating the results with IBD treatment.

METHODS

From July 2015 - March 2017, 100 patients were enrolled and divided in four groups of 25 participants each, according to in course treatment. Blood collections were performed every 5 months in all patients. Antibodies for EBV and HPVB19 were screened and repeated if negative. Blood EBV DNA, HPVB19 DNA, and HHV6 DNA were quantified by quantitative real-time Polymerase Chain Reaction.

RESULTS

Patients had evidence of EBV (100 %) and HPVB19 (70 %) past infection. Across the study timeline, EBV-DNA, HPVB19-DNA, and HHV6-DNA were detected in the blood of 25, 11, and 7 patients, respectively. Viremia was detected only once in 72 %, 73 %, and 86 % of the patients in the studied period, for EBV, HPVB19, and HHV6, respectively. We did not find significant differences between treatment groups, independently of the viral cut-off for the three viruses.

CONCLUSIONS

The detection of EBV, HPVB19, and HHV6 viremia, in stable CD patients, was not impacted by biological/immunosuppressant therapy. Although attractive as a non-invasive technique, this approach did not prove to be useful in stable patients. More and larger studies are needed to address the relevance of these viruses on IBD course, in stable patients and during exacerbations.

Candidemia in a Portuguese tertiary care hospital: Analysis of a 2-year period

BACKGROUND

Candidemia is a nosocomial infection of increasing importance, associated with high morbidity and mortality. The aim of this study is to describe the species distribution, risk factors, management and outcomes of patients with candidemia.

METHODS

We conducted a retrospective study at Centro Hospitalar Universitário de São João, Portugal, between January 2016 and December 2017.

RESULTS

A total of 117 candidemia episodes (n=114 patients) were included. Median age was 65 years, with an increased prevalence of older ages. Candida albicans (51.3%) was the most prevalent species, followed by C. glabrata (22.2%), C. parapsilosis (15.4%), C. tropicalis (4.3%) and C. lusitaniae (2.6%). Forty-two patients (35.9%) did not receive antifungal drugs after diagnosis of candidemia. Echinocandins were used as first-line drug therapy in half of the treated patients (50.7%). The median EQUAL Candida Score was 6/17 (IQR 6-9) for patients without central venous catheter (CVC) and 11/20 (IQR 6-14) for patients with CVC. The 30 days-mortality was 31,6% and was not significantly associated with the timing of antifungal therapy and the EQUAL Candida Score.

CONCLUSION

The distribution of Candida species has changed in recent years, with an increase in the proportion of C. albicans and C. glabrata. Rapid diagnostic tests, empiric antifungal therapy and source control are essential to improve the prognosis of patients with candidemia. More multicentric prospective studies are needed to evaluate the association of mortality with the timing of antifungal therapy or the EQUAL Candida Score.

Chronic meningococcemia

The spectrum of Neisseria meningitidis-associated clinical entities involves mild forms of disease, without neurological involvement or sepsis, and asymptomatic carrier states. Rarely, N. meningitidis bacteremia can be associated with a prolonged fever with or without arthritis, which we designate as chronic meningococcemia. Chronic meningococcemia is an uncommon entity, usually associated to serogroup B N. meningitidis. Diagnosis is frequently delayed as blood cultures collected outside febrile periods can be negative. We present a case of chronic meningococcemia in a 22-year-old woman with no relevant clinical background, presenting with fever, arthralgia and exanthem. Due to the potential for progression to more severe disease and the risk of N. meningitidis transmission and development of secondary cases, a high degree of clinical suspicion is required to ensure prompt recognition and adequate treatment. Our patient had a favorable outcome probably due to early recognition and adequate treatment, which is critical for the resolution of the disease without complications.