Clinical Case of Parvovirus B19 Infection in Pregnant Woman with Β-Thalassemia in Bulgaria

A pregnant 30-year-old female in the 34th gestational week was admitted at University "Maichin Dom" Hospital prior to childbirth. The patient is diagnosed with β-thalassemia. During laboratory screening hemoglobin of 98 g/L was established. Blood smear shows mild microcytic hypochromic anemia: RBC 5.15 x 1012/L, HGB 98 g/L, MCV 65.8 fL, MCH 19.4 pg, MCHC 295 g/L. Serum iron concentration is 12.9 µmol/L and ferritin 17.5 µg/L. For the delivery process cesium was considered. Two days after procedure a rash presented on face, hands and breasts. Although the mother was positive for parvovirus B19 infection, the baby was negative. This was confirmed by se-rological and molecular investigations. We discovered only the mother's B19V IgG antibodies in the newborn. In connection to the main disease, namely β-thalassemia, acute virus infection could cause aplastic crisis. After consultation with a hematologist, serum hepcidin concentration (an iron homeostasis regulator) was quantified: 19.4 µg/L. ELISA test was used to prove B19V IgM antibodies in the mother. PCR analysis shows the presence of B19V DNA. During infection, inflammatory cytokines increase hepcidin secretion, leading to iron deposition into cells.

Acute fibrinolysis shutdown occurs early in septic shock and is associated with increased morbidity and mortality: results of an observational pilot study

BACKGROUND

Septic coagulopathy represents a very dynamic disease entity, tilting from initial hypercoagulability towards a subsequent hypocoagulable disease state, entitled overt disseminated intravascular coagulation. Acute fibrinolysis shutdown has recently been described to be a crucial component of initial hypercoagulability in critically ill patients, although the underlying pathomechanisms, the specific temporal kinetics and its outcome relevance in patients with sepsis remain to be determined.

METHODS

In total, 90 patients (30 with septic shock, 30 surgical controls and 30 healthy volunteers) were enrolled. Blood samples were collected at sepsis onset or prior and immediately after the surgical procedure as well as 3 h, 6 h, 12 h, 24 h, 48 h and 7 d later, whereas blood samples from healthy volunteers were collected once. Besides viscoelastic and aggregometric point-of-care testing (POCT), enzyme-linked immunosorbent and thrombin generation assays and liquid chromatography-mass spectrometry-based measurements were performed.

RESULTS

As assessed by viscoelastic POCT, fibrinolysis shutdown occurred early in sepsis. Significant increases in tissue plasminogen activator had no effect on thromboelastometrical lysis indices (LIs). Contrariwise, plasminogen activator inhibitor-1 was already significantly increased at sepsis onset, which was paralleled by significantly increased LIs in patients suffering from septic shock in comparison with both control groups. This effect persisted throughout the 7-day observation period and was most pronounced in severely ill as well as non-surviving septic patients. Thromboelastometrical LI, therefore, proved to be suitable for early diagnosis [e.g. LI 45 min: area under the curve (AUC) up to 0.933] as well as prognosis (e.g. LI 60 min: AUC up to 1.000) of septic shock.

CONCLUSIONS

Early inhibition of plasminogen activation leads to acute fibrinolysis shutdown with improved clot stability and is associated with increased morbidity and mortality in septic patients. Trial registration This study was approved by the local ethics committee (Ethics Committee of the Medical Faculty of Heidelberg; Trial-Code No. S247-2014/German Clinical Trials Register (DRKS)-ID: DRKS00008090; retrospectively registered: 07.05.2015). All study patients or their legal representatives signed written informed consent.

[NEW APPROACH IN DIAGNOSTIC ALGORITHM OF AN INFECTIOUS AGENTS (PARVOVIRUS B19 AND CHLAMYDIA TRACHOMATIS) INVOLVED IN THE DEVELOPMENT OF PATHOLOGICAL PREGNANCY]

Viral infections during pregnancy, along with some form of accompanying pregnancy diseases such as diabetes, cardiovascular, gastrointestinal, kidney and others, are a major cause of arising complications and mortality of mother and fetus.

AIM

To improved the laboratory diagnostic approach in the study of women with pathological pregnancy, including improve treatment and prognostic character of the outcome of pregnancy, with the inclusion of two infectious agent parvovirus B19 and Chlamydia trachomatis. To determine types of anemia in pregnant women with parvovirus B19 and Chlamydia trachomatis infection and to select the correct therapeutic approach.

MATERIALS AND METHODS

A total 36 serum samples from pregnant women with anemia (n = 22), nonimmune hydrops fetalis (n = 8) and fetal ascites (n = 6) were tested. The study included three newborns (n = 3), tested on the occasion of a possible maternal-fetal infections. The serological (indirect ELISA tests) and molecular (B19V-PCR test) methods were used. In anemic pregnant women were evaluated iron homeostasis parameters with CLIA, AAS and NEPH methods.

RESULTS

In 6/36 (16.66%) patients B19V-IgM positive result was detected. Among the study patients with anemia, non-immune hydrops fetalis and fetal ascites incidence of proven B19V-IgM antibodies was 18.18% (4/22), 12.5% (1/8) and 16.66% (1/6), respectively. Protective B19-IgG antibodies in 25/39 (64.10%) samples were found. A positive PCR signal was showed in all patients with positive B19V-IgM, and 1 patient with anemia and positive B19V-IgG result. The three newborns were positive for B19V-IgG antibodies (maternal) and negative for acute viral infection. Present Chlamydia trachomatis infection in 6/36 (16.66%) and past infection in 5/36 (13.89%) patients was demonstrated. The anemia was evaluated as iron-deficiency according to low hepcidin levels 2.54 ± 0.4 μg/I compared to pregnant control group which included women without anemia 25.9 ± 2.8 μg/I.

CONCLUSION

In view of the varied transmission B19V and the wide range of complications arising as a result of chlamydia, screening for these viral agents of pregnant women and women of childbearing age is an important approach for monitoring of pregnancy.

Preanalysis in Serum Hepcidin Measurement

BACKGROUND

Hepcidin is a 25-amino peptide hormone that regulates iron homeostasis. Its serum quantification helps to provide the right therapeutic choice in iron-deficiency anemia and anemia in chronic diseases. Diurnal levels of serum iron might affect hepcidin secretion during the day. Blood collection time is an important part of the preanalytical phase of its quantification.

METHODS

During the period 2013 - 2014, we collected blood samples for serum hepcidin quantification in 100 healthy controls. The samples were collected in vacuettes with serum separator gel at three different times during the day: 07:30 - 08:30, 12:00 - 13:00, and 16:00 - 17:00 hours. Hepcidin levels were measured with an ELISA method.

RESULTS

We found a significant difference in serum hepcidin levels during the chosen three blood taking times. The normal range for Bulgarian population is 3.05 μg/L - 37.75 μg/L. The measured levels were: at 07:30 - 08:30 hours 12.2 μg/L (5.5 μg/L - 23.6 μg/L), 12:00 - 13:00 hours 14.1 μg/L (7.1 μg/L - 27.2 μg/L), and 16:00 - 17:00 hours 16.5 μtg/L (9.9 μg/L - 29.6 μpg/L) 10.7 < r < 1.0; p < 0.5 between 07:30 - 08:30 and 12:00 - 13:00 hours and p < 0.05 between 07:30 - 08:30 hours and 16:00 - 17:00 hours and 12:00 - 13:00 hours and 16:00 - 17:00 hours]. No significant differences were found for transferrin saturation between measured groups [0.1 < r < 0.3; p > 0.5].

CONCLUSIONS

In order to obtain the most correct results for serum hepcidin quantification (especially in border to referent range levels) in the preanalytical phase, it is important to consider the time of blood sampling.

[SERUM HEPCIDIN LEVELS IN ENDOMETRIOSIS]

OBJECTIVE

Endometriosis is a benign disease, which ranks third in mortality from gynecological morbidity after inflammatory conditions and myoma. We tried to evaluate serum iron and hepcidin levels and seek their connection with the development of endometriosis.

METHODS

For quantification of serum hepcidin we use ELISA method. 53 women were included, average age 25.4 ± 4.3. They were divided into two groups--women with endometriosis (EM) and a control group. Samples were taken at the University hospital "Maichin dom" for a period of one year. We measure serum iron, ferritin and calculate transferrin saturation. We use the Pearson's correlation and Student's t-test for evaluating of statistical significance.

RESULTS

We found statistically significant differences in serum hepcidin levels in the groups included: women with endometriosis have higher concentrations 64.3 ± 7.8 μg/L compared to the control group 19.4 ± 4.1 μg/L (r = -0.201, P < 0.001). Serum ferritin levels showed significant differences between the two groups in EM 17.9 ± 8.4 ng/ml vs control 79.5 ± 14.6 ng/ml (r = -0.249, P < 0.001). Statistically significant difference was found in serum iron levels: in EM 21.9 ± 3.2 μmol/L compared to 13.5 ± 1.9 μmol/L in the control group (P < 0.001).

CONCLUSION

Our results support the idea that iron overload and increased serum levels of hepcidin plays an important role in the pathogenesis of endometriosis.

[Plasma D-dimer levels in preeclampsia]

Preeclampsia is a multifactorial disease characterized by hypertension and proteinuria after 20 weeks of gestation of the pregnancy. Preeclampsia is characterized by the deposition of fibrin in the walls of small blood vessels. D-dimer was used as a marker for degradation/synthesis of fibrin in vivo. D-dimer has emerged as a useful indicator in the diagnosis of thrombotic conditions because its plasma concentration has a high predictive value for the assessment of venous thromboembolism. The purpose of this study was to evaluate plasma levels of D-dimer and preeclampsia compared to normal pregnancy occurs. We found that elevated levels of D-dimer is associated with the development of preeclampsia in the third trimester of pregnancy compared with normal pregnancy occurs. Preliminary findings highlight the need for further in-depth studies during pregnancy in order to fully clarify the diagnostic/prognostic role of D-dimer preeclampsia.

[PlGF and sFlt-1--diagnostic significance in preeclampsia prediction in pregnant women with gestational and chronic hypertension]

Preeclampsia (PE) is characterized with hypertension and proteinuria after 20 gestational weeks. and is the major reason for maternal and fetal mortality during pregnancy. Etiology of PE is still unclear. Clinical manifestation is connected to high levels of circulated anti-angiogenic proteins such as soluble Fms-like tyrosine kinase 1 (sFlt1) and soluble endolgin (sEng). Furthermore PE leads to low serum levels of Placental growth factor (PIGF). The change of these serum levels appears before clinical manifestation, which makes them useful for screening of pregnant women with high risk of PE. This opportunity for prediction of PE would significantly lower the mortality caused by PE. We measure serum sFlt-1 and PIGF levels in pregnant women with normal and pathological pregnancy including gestational and chronic hypertension without PE. Population included 23 pregnant women during a period of two years. Comparison between the groups was made with parametric Student's test. A level of p < 0.05 was accepted as statistically significant. Eight women were with PE (one of them with chronic hypertension). Six pregnant women were with isolated hypertension (four with chronic and 2 with gestational hypertension). Nine pregnant women were with normal pregnancy. Serum sFlt-1 and PIGF levels showed significant differences in pregnant women in between 25th and 28th gestational weeks: a) for sFlt-1--in PE (4859.88 pg/ml) and normal pregnancy (3125.53 pg/ml)--p = 0.0002 or isolated hypertension (2791.40 pg/ml)--p = 0.0054 and b) for PIGF--in PE (206.63 pg/ml) and normal pregnancy (667.87 pg/ml)--p = 0.0011 or isolated hypertension (560.20 pg/ml)--p =0.0125. Our study shows that serum sFlt-1 and PIGF levels significantly changes during pregnancy and before clinical manifestation of PE (minimum in 15.5 gestational weeks).

[Potential for diagnosis in preeclampsia]

Preeclampsia (PE) is characterized with hypertension and proteinuria after 20 gestational weeks and is the major reason for maternal and fetal mortality during pregnancy. Etiology of PE is still unclear. Cliniical manifestation is connected to high levels of circulated anti-angiogenic proteins such as soluble Fms-,like tyrosine kinase 1 (sFlt1) and soluble endolgin (sEng). Furthermore PE leads to low serum levels of Placental growth factor (PIGF). The change of these serum levels appears before clinical manifestation, which makes them useful for screening of pregnant women with high risk of PE. This opportunity for prediction of PE would significantly lower the mortality caused by PE. We measure serum sFlt-1 and PIGF levels in pregnant women with normal and pathological pregnancy, including gestational and chronic hypertension without PE. Population included 40 pregnant women during a period of two years. Comparison between the groups was made with parametric Student's test. A level of p < 0.05 was accepted as statistically significant. Ten women were with PE. Fifteen pregnant women were with chronic kidney disease without hypertension. Fifteen pregnant women were with normal pregnancy (control group). Serum sFlt-1 and PIGF levels showed significant differences in pregnant women with PE compared to control group and CKD patients: a) for sFlt-1--in PE (4971.25 pg/ml) and normal pregnancy (3125.53 pg/ml)--p < 0.005 or CKD (3145.80 pg/ml)--p = 0.0032 and b) for PIGF--in PE (206.63 pg/ml) and normal pregnancy (667.87 pg/ml)--p = 0.0011 or CKD (643.13 pg/ml)--p = 0.003. Our study shows that angiogenic factors may aid in differentiating between PE caused by angiogenic imbalance and by renal function worsening.

[Early detection of possibilities for preeclampsia using VEGF1 and other serum analysis]

INTRODUCTION

The aim of our study is to establish an interaction between serum VEGF1 levels and possibilities of early detection of preeclampsia.

METHODS

For a period of three months we follow up 17 patients with preeclampsia in second trimester by measuring serum levels of VEGF1, PIGF and Inhibin A. A correlation between them was determined.

RESULTS

During our study we investigate 17 patients with preeclampsia and 35 as a control group. Significant differences between serum levels in too groups were established. Serum levels for VEGF1 above 158.5 pg/ml; Inhibin A above 98.50 ng/ml; PIGF levels above 30.01 pg/ml shows a diagnostic sensitivity 88.895 and diagnostic specificity 97.06% in prediction of preeclampsia.

CONCLUSION

Measurement of serum VEGF1, PIGF and Inhibin A levels are suitable for early prediction of possibilities for preeclampsia in second trimester. These results are the basis for further studies in this field.

[HE4 and CA125 in ovarian cancer]

INTRODUCTION

Ovarian cancer is forth reason that causes mortality in women all over the world. In Europe the death is 3.6 up to 9.3 in 100000 women. HE4 is a newly, more specific diagnostic marker for ovarian cancer. Human epididimis protein 4 (HE4) belongs to a group with four disulfide core proteins. It is first identified in the epithelium of distal epididimis and thought to be a protease inhibitor that took part in sperm maturation. HE4 is expressed from ovarian cancer cells.

METHODS

Measurement of HE4 is uncompetitive immunoassay, based on direct sandwich technique. It uses monoclonal antibodies, against specific molecule epitopes, coated onto the microstrips. After the incubation, enzyme-linked monoclonal antibodies are added; a substrate reagent solution leads to a color reaction, which intensity is proportionate to the amount of HE4 present in the samples.

RESULTS

For a 12 months period we measure 50 patients doubt about ovarian cancer (with formation in pelvis). We include a control group from 50 patients with no ultrasonographic or laboratory evidences of ovarian cancer. The age was between 25 and 60. The middle age for patients with carcinoma was higher compared to those without tumor process (respectively 51.1 to 46.7; p = 0.018). From the group with doubt for an ovarian cancer 40 cases were with EOC, 9 with benignant tumors (ovarian cysts), 1 with no deviation from the normal ovarian tissue. From the patients with EOC--32 cases were with serous tumor, 7 with mucinous, 1 were undifferentiated.

CONCLUSION

HE4 is more specific marker to be used for early diagnosis of ovarian cancer. It's frequently using will decrease mortality of this social disease.

[HE4--a new tumor marker for ovarian cancer]

AIM

Ovarian cancer is the fourth most common cause of cancer-related death in women worldwide. In Europe, the mortality rate range is from 3.6 to 9.3 per 100 000 women; the symptoms are mostly unspecific. Compared to often used CA 125 HE4 is a tumor marker that provides more specific and earlier diagnostic of ovarian cancer.

MATERIAL AND METHODS

The HE4 is a solid-phase, non-competitive immunoassay. After the required incubation an enzyme-linked monoclonal antibody are added; followed by substrate solution, which develops color reaction in proportion to the amount of HE4 in serum.

RESULTS

For a period of seven months we investigate 55 patients for ovarian cancer. The age was between 25 and 60. In 17 cases the levels of HE4 and CA125 were both elevated. In 8 cases we found no deviation from the normal ranges. In the rest 30 cases the levels of He4 were high, in spite of low CA125 levels. The followed biopsies confirmed the diagnosis ovarian cancer.

CONCLUSION

HE4 is vastly more specific and early-phase diagnosed tumor marker in cases with ovarian cancer. Its common usual would reduce the mortality from this social disease.

[Measurement of basal inhibin B level in Bulgarian women of the childbearing age]

OBJECTIVE

To establish mean and reference range of basal serum inhibin B levels in a group of healthy fertile Bulgarian women.

METHODS

The present report covers the results of 9 month's period in which sixty-five healthy fertile Bulgarian women, aged 20-40 years were selected to determinate a reference group of healthy fertile women with normal values of inhibin B. Blood samples were collected on early follicular phase of menstrual cycle (2-4 days). Inhibin B was analyzed in duplicate with the use of a double-antibody ELISA.

RESULTS

We established mean values of inhibin B 121.22 (+/- 45.04) pg/ml in a group of 65 healthy fertile Bulgarian women with mean 30.78 (+/- 3.94) years of age. The values of inhibin-B, which we obtained in the 5th percentile, was 33.15 pg/ml and in the 95th percentile was 190.75 pg/ml.

CONCLUSIONS

The measurement of inhibin B is a test easy for performance, with reference values for healthy fertile Bulgarian women between 33.15 pg/ml and 190.75 pg/ml.