Vol 83, No 11 (2011)


"Medicine of the future is preventive medicine" N.I. Pirogov

Solov'eva A.A., Tsapkova N.N., Pokrovskiy V.I., Solovyeva A.A., Tsapkova N.N., Pokrovsky V.I.


The role of N.I. Pirogov is shown in the study of infectious factors significance in high mortality during the Crimean war combats. He recommended important organizational, sanitary and therapeutic measures both in war and peacetime conditions.
Terapevticheskii arkhiv. 2011;83(11):5-9
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Immunological aspects of HCV/HIV coinfection

Yushchuk N.D., Shestakova I.V., Balmasova I.P., Vysheslavtseva M.V., Shmeleva E.V., Yuschuk N.D., Shestakova I.V., Balmasova I.P., Vysheslavtseva M.V., Shmeleva E.V.


Aim. To evaluate effects of HCV/HIV coinfection on blood lymphocyte phenotype including cells CD56+. Material and methods. We studied standard immunogram, subpopulational composition and functional activity of blood cells CD56+ in 67 patients with verified diagnosis of HIV infection and virus hepatitis C. Results. We discovered some pathogenetically sound indices of immune status in patients with HCV/ HIV coinfection. Some of the immune shifts detected changed in response to intake of narcotic drugs, antiretroviral treatment, hepatic cirrhosis, pneumonia. Conclusion. Parameters of subpopulational composition and functional activity of cells CD56+ in the blood of patients with HCV/HIV coinfection elucidate some unknown features of the above infectious process which should be considered in this coinfection treatment and prophylaxis.
Terapevticheskii arkhiv. 2011;83(11):9-14
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Diagnosis of tuberculous pericarditis in patients with HIV-infection

Toshchevikov M.V., Zimina V.N., Batyrov F.A., Kravchenko A.V., Vasil'eva I.A., Toschevikov M.V., Zimina V.N., Batyrov F.A., Kravchenko A.V., Vasilieva I.A.


Aim. To study specific features of the incidence, course and diagnosis of tuberculosis pericarditis (TP) in patients with HIV-infection. Material and methods. We analysed results of diagnosis of 304 primary patients with organ tuberculosis in combination with HIV infection treated in Moscow tuberculosis hospital N 7 in 2006-2010. CD4 lymphocyte count median in tuberculosis onset was 140 in 1 mcl, 63.2% patients had a baseline level of CD4 lymphocytes under 200 in 1 mcl. Results. TP incidence in primary patients with tuberculosis and HIV-infection was 6.3% while in patients with tuberculosis of multiple locations - 13.7%. Cardiac tamponade symptoms were registered only in one case. Pericardial effusion was classified as moderate and large in 68.4% patients. Patients with large effusion (more than 20 mm in isolation of pericardial leaves) have undergone diagnostic pericardiocentesis and, in some cases, microdrainage. Sensitivity of exudate test for M. tuberculosis DNA with use of polymerase chain reaction was 100%. Conclusion. Active surgical policy in massive effusion tuberculosis pericarditis in line with adequate antituberculosis and antiretrovirus therapy in HIV-infecterd patients results in rapid resorption of the effusion.
Terapevticheskii arkhiv. 2011;83(11):14-19
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Current course of pneumocystic pneumonia in HIV-infected patients

Ermak T.N., Samitova E.R., Tokmalaev A.K., Kravchenko A.V., Ermak T.N., Samitova E.R., Tokmalaev A.K., Kravchenko A.V.


Aim. To describe clinical and laboratory characteristics of pneumocystic pneumonia (PP) in patients with HIV-infection for improvement of diagnosis quality. Material and methods. Detailed examination was performed in 111 HIV-infected patients with suggested diagnosis of PP. The following investigations were made: clinical, x-ray examinations, total count and biochemical blood tests, enzyme immunoassay, indirect immunofluorescence reaction (IIFR) for Pneumocystis jiroveci antigens in bronchoalveolar lavage fluid (BALF)or induced sputum. For diagnosis of other secondary diseases PCR was used for investigation of BALF and bronchial biopsy to detect DNA of Mycobacterium tuberculosis complex, Candida albicans, Cytomegalovirus, Toxoplasma gondii, Mycoplasma spа., Herpes simplex I, II. DNA of cytomegalovirus in blood was detected with PCR. Microscopic tests of the sputum were conducted for detection of acid-resistant mycobacteria. Results. PP was associated with other secondary diseases in 59% patients (pulmonary tuberculosis - 16%, CMV pneumonia - 31%, combination of all the lesions - 5%).PP diagnosis was cancelled and pulmonary tuberculosis was diagnosed in 12 patients.In combination of PP with other pathology dominant were symptoms observed in PP monoinfection and only effective anti-pneumocystic treatment revealed signs of comorbid pathology. Tuberculosis patients had weaker signs of respiratory failure, symmetric bilateral interstitial or small-focal alterations were detected less frequently. Conclusion. Current PP course characteristics in HIV infection are identified. In clinical diagnosis of PP special attention should be paid to data complex especially to increasing respiratory failure, high ESR, elevated lactate dehydrogenase, low blood pO2, fast response to ex juvantibus therapy. The most effective method of the diagnosis verification - BALF IIFR.
Terapevticheskii arkhiv. 2011;83(11):19-24
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Analysis of lethal outcomes in patients with newly-diagnosed tuberculosis of the respiratory organs in combination with HIV-infection

Zimina V.N., Kravchenko A.V., Zyuzya Y.R., Batyrov F.A., Popova A.A., Klimov G.V., Parkhomenko Y.G., Vasil'eva I.A., Zimina V.N., Kravchenko A.V., Zyuzya Y.R., Batyrov F.A., Popova A.A., Klimov G.V., Parkhomenko Y.G., Vasilieva I.A.


Aim. To analyse lethal outcomes in patients with newly-diagnosed respiratory tuberculosis comorbid with HIV-infection depending on initial count of CD4+ lymphocytes. Material and methods. Of 304 HIV patients with newly-diagnosed tuberculosis treated in Moscow Tubercusis Hospital N 7 in 2006-2010, 40 (13.2%) patients died. Tuberculosis diagnosis was made after detection of M.tuberculosis (MT) by different tests, MT DNA in different biological material, histological verification or by effectiveness of specific antituberculous therapy. Postmortem examinations were made according to the protocol. Results. Significant differences were detected in patients with initial count of CD4+ lymphocytes less than 50 in 1 mcl. Specific CNS affection was found in patients with initial lymphocyte count CD4+ less than 100 in 1 mcl. Most of autopsy examinations registered generalized acutely progressive tuberculosis with multiple lesions of internal organs and lymph nodes (LN). Microscopy revealed obscure morphological picture of specific inflammation with prevalence of alternative-exudative tissue reactions in the absence of a productive inflammation component. Cases with submiliary dissemination which was invisible in macroscopic examination due to a bright picture of exudative tissue reaction (rare plethora of the lungs, alveolar and interstitial edema, perifocal inflammatory reaction of nonspecific reactive nature) and small size of the lesions. The comparison of clinical and autopsy diagnoses revealed that involvement of intrathoracic LN and miliary dissemination, according to autopsy, occurred much more frequently than shown by antemortem standard x-ray examination of the chest. Conclusion. It is strongly recommended to perform computed tomography of the chest in all HIV-infected patients with long-term fever but without visible alterations on chest x-ray.
Terapevticheskii arkhiv. 2011;83(11):25-31
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Specific features of lymphoid infiltration in liver biopsy in patients with chronic viral hepatitis B and C

Umbetova K.T., Lazareva A.S., Kiselevskiy M.V., Parkhomenko Y.G., Volchkova E.V., Pak S.G., Umbetova K.T., Lazareva A.S., Kiselevsky M.V., Parkhomenko Y.G., Volchkova E.V., Pak S.G.


Aim. To study characteristics of leukocytic infiltration of the liver in patients with chronic viral hepatitis B and C (CVHB and CVHC) with consideration of hepatitis activity and fibrosis severity. Material and methods. The examination of 37 patients with CVHB (n = 13) and CVHC (n = 24) included liver puncture biopsy by Mengini, subsequent histological and morphological investigation of liver biopsy with immunohisto- and immunocytochemistry. Results. In CVHB and CVHC patients leukocytic infiltrates (LI) of the liver present primarily with T-lymphocytes (CD3+), NKT cells (CD3+CD16+CD56+), NK cells (CD16+CD56+), T-regulatory lymphocytes (CD4+CD25+), cytotoxic T-lymphocytes (CD8+). Cytotoxic lymphocytes (CD8+) and NK cells (CD16+CD56+) detected in hepatic LI of patients with chronic viral hepatitis are similar in composition with cells in hepatic tissue infiltrates in autoimmune hepatitis. We are the first to detect the complex of T-regulatory cells (CD4+CD25+)in hepatic parenchyma of these patients. This complex suppresses cellular immune response in virus elimination and damaged tissues and supports development of persistent viral infection with autoimmune component. Conclusion. The complex of T-regulatory cells (CD4+CD25+) isolated in hepatic LI evidences for existence of a morphofunctional base for autoimmune manifestations in the presence of persistent viral infection.
Terapevticheskii arkhiv. 2011;83(11):31-33
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Markers of intestinal infection agents in patients with acute viral hepatitis with cholestatic syndrome

Zuevskaya S.N., Belaya O.F., Volchkova E.B., Andrekayte N.A., Zuevskaya S.N., Belaya O.F., Volchkova E.V., Andrekaite N.A.


Aim. To study the pathogenetic role of agents of the most common intestinal infections in the development of cholestatic syndrome in patients with acute viral hepatitis. Material and methods. We investigated 97 patients with acute viral hepatitis (AVH), 112 blood donors and 165 patients with acute bacterial intestinal infections (ABII). O-antigens of the major causative agents of infections in feces and serum (CIC) and the presence of antishigatoxic CIC in the serum were found. Results. It is first shown a high incidence of O-antigens of Salmonella, Yersinia, Helicobacter, Shigella and Campylobacter in 81,4% of patients with AVH, more frequent and prolonged their detection in patients with the syndrome of cholestasis, higher total O-antigenic load, the frequent identification of mixed-antigens, high levels of LII in comparison with patients without AVH cholestasis and with acute intestinal infections patients. One-third of patients with AVH revealed antishigatoxic CIC in blood serum, which is lower than in patients with ABII. Conclusion. The findings suggest the importance of intestinal infections agents in the development and maintenance of inflammation in the liver, the prognostic value of identifying markers in patients with AVH, especially with the syndrome of cholestasis.
Terapevticheskii arkhiv. 2011;83(11):34-38
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Specific damage to the kidneys in patients with chronic hepatitis C associated with cryoglobulinemia

Milovanova S.Y., Tegay S.V., Russkikh A.V., Kozlovskaya L.V., Milovanova S.Y., Tegai S.V., Russkikh A.V., Kozlovskaya L.V.


Aim. To reveal clinical and morphological characteristics of renal damage in patients with cryoglobulinemia (CGE) associated with chronic viral hepatitis C (CVH-C) for upgrading diagnosis, prognosis and optimization of the treatment methods. Material and methods.Њ Two groups of CVH-C patients were studied: with CGE (group 1, n = 64) and free of CGE (group 2, n = 62) matched for gender, age and duration of the disease. Biopsy of the liver for assessment of the histological activity index and histological sclerosis index by METAVIR scale was conducted in 63 patients. Of patients with CGE-related damage to the kidneys, 48 were examined for clinical picture with morphological investigation of renal tissue in 15 of them including semiquantitative evaluation of fibrosis degree and activity. Results. Patients with CVH-C and CGE had a wider spectrum of systemic lesions than CVH-C patients without CGE. Only CGE patients demonstrated more severe affection of the skin, joints, kidneys and the nervous system. Therefore, CGE can be considered as a marker of poor prognosis. Liver biopsy showed that CGE patients had more pronounced fibrosis (3-6 points) versus 0-2 points in 80% patients from group 2. Duration of CVH-C from probable infection to renal damage in 48 patients with CGE glomerulonephritis (GN) averaged 197.05±18.5 months. Renal biopsy diagnosed CGE mesangiocapillary GN in 13 patients and membranoproliferative GN in 2 patients. Patients with HCV infection had a more severe proliferative form of nephritis - mesangiocapillary GN. In 48 GN patients with HCV-infection and CGE, GN ran latently with moderate urinary syndrome in 29 (60.4%) patients, with nephrotic syndrome - in 9 (18.6%), with acute nephritic syndrome - in 10 (21.0%) patients. Most of the patients had arterial hypertension, 13 patients had creatinemia (3.02±0.55 mg/dl), rapidly progressive GN was diagnosed in 4 patients. Conclusion. Persistent CGE marks poor prognosis in CHC patients and is an indication for antiviral treatment to prevent severe organ lesions, first of all of the kidneys. Development of CGE vasculitis with severe damage to the kidneys demands immunosuppressive therapy in combination with plasmapheresis or cryapheresis followed by antiviral drugs. As shown by pilot results, a new approach with rituximab is perspective but further evidence is needed for final conclusions.
Terapevticheskii arkhiv. 2011;83(11):38-44
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Perspectives of prevention and treatment of Herpes Symplex with regular recurrence

Isakov V.A., Ermolenko D.K., Isakov D.V., Isakov V.A., Ermolenko D.K., Isakov D.V.


Aim. To assess efficacy of two-stage treatment of severe genital herpes (GH) with regular recurrences: combined use of antivirus medicines with interferon preparations and its inductors followed by antirecurrence vaccine therapy. Material and methods. Two-stage treatment was given to 100 patients suffering from GH with severe regular recurrences. One-stage treatment included famvir in combination with interferon(viferon) or interferon inductors (amixin,cycloferon) and antioxidants. Stage two treatment consisted of vaccine therapy of patients who failed prophylactic standard vaccination by allergometric technique. Results. The first stage treatment prolonged recurrence-free period 2-3-fold in more than 85% patients, improved quality of life. Stage-two treatment resulted in long-term clinicoimmunological remission which is necessary for conduction of anti-recurrence vaccine treatment. Conclusion. Changes in therapeutic-preventive policy in patients with recurrent GH with regular recurrence (2 stage of treatment) prolong recurrence-free intervals, improve quality of life and social adaptation of patients.
Terapevticheskii arkhiv. 2011;83(11):44-47
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Leptospirosis and its complications

Nafeev A.A., Vetlugin N.I., Feofanova S.G., Nechaeva A.S., Savinova G.A., Nafeev A.A., Vetlugin N.I., Feofanova S.G., Nechaeva A.S., Savinova G.A.


Leptospirosis (Weil-Vasiliev disease) is a zoonotic natural focal disease running as an acute fever with severe intoxication, lesion of the kidneys, liver, CNS, hemorrhagic syndrome, complications, frequent lethal outcomes. Clinical features of leptospirosis in patients with comorbid diseases are not studied adequately. Lethal outcomes are often caused by such serious complications as infectious-toxic shock, acute renal-hepatic failure, massive hemorrhagic syndrome, infectious myocarditis, etc. Two cases of leptospirosis with irreversible complications are reported: one case with severe lesion of the kidneys and heart, and the other case with lethal damage to the kidneys. The evidence for a severe course of leptospirosis complicated with renal insufficiency is provided. Lethal outcomes in leptospirosis are often associated with late diagnosis because of the disease manifestation similarity with such diseases as hemorrhagic fever and renal syndrome. It is shown that leptospirosis runs a very severe cause in exacerbation of preexisting infection or somatic disease. The necessity of consideration of the background pathology demands an early and individual correction of diagnostic algorithms, conduction of etiotropic and pathogenetic therapy, rehabilitation measures. Comorbid diseases in leptospirosis patients have an essential negative effect on leptospirosis clinical picture, on a course of infectious process (aggravation of endogenic intoxication, polyorganic disorders, nonspecific complications).
Terapevticheskii arkhiv. 2011;83(11):48-51
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Implication of functional platelet activity in pathogenesis of Q-fever

Lazareva E.N., Maleev V.V., Galimzyanov K.M., Burkin A.V., Polyakova A.M., Astrina O.S., Babaeva M.A., Khok M.M., Lazareva E.N., Maleev V.V., Galimzyanov K.M., Burkin A.V., Khok M.M., Polyakova A.M., Astrina O.S., Babaeva M.A.


Aim. To ascertain the role of platelets in pathogenesis of clinical symptoms in patients with Q-fever. Material and methods. We studied hemostasis with estimation of functional platelet activity in 49 patients with Q-fever. Results. Hemorrhagic syndrome (HS) occurred in 34,4 % patients with Q-fever (QF) during seasonal rise of morbidity. HS manifested with petechiae (12%), hematomas (32 %), nasal bleeding (17 %), stomatorrhagia (9 %), melena (12 %). Characteristics and duration of such symptoms as weakness (100%), myalgia (72%), arthralgia (52.9%) suggested hemocoagulatory disorders as a cause of the symptoms appearance. At the height of the disease thrombocytopenia was accompanied with inhibition of platelet aggregation activity, but regression of the clinical symptoms was associated with an increase in platelet count and platelet hyperaggregation. Fibrinogen content was elevated during hospitalization in 50% patients. Conclusion. Clinical manifestations of HS are typical for Q-fever prevalent in the Astrakhan Region. Hemostatic disorders because of altered functional activity of platelets were registered in all the cases and evidence for pathogenetic unbalance of homeostasis in Q-fever patients.
Terapevticheskii arkhiv. 2011;83(11):51-55
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Comparative characteristics of transmissive fevers in the territory of Astrakhan region (clinicoepidemiological evidence)

Pokrovskiy V.I., Ugleva S.V., Shabalina S.V., Pokrovsky V.I., Ugleva S.V., Shabalina S.V.


Epidemiologists register a trend in the latest decades for expansion of the areas of natural-focal transmissive fevers morbidity in the Astrakhan region. This is explained by reconfiguration of natural landscapes as a result of increasing anthropogenic impact. The Astrakhan territory exclusively contains 4 types of landscape with evolutionally formed several natural foci of transmissive fevers: Crimean hemorrhagic fever, West Nile fever, Astrakhan rickettsial fever, Q-fever. Early diagnosis of these diseases determines further treatment, prophylactic policy in the infection focus.
Terapevticheskii arkhiv. 2011;83(11):55-59
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Pneumonia or drug-related exogenic allergic alveolitis? Key role of anamnesis in differential diagnosis

Skipskiy I.M., Efimov N.V., Dantsig I.I., Matyukhina L.M., Kostina O.Y., Skipsky I.M., Efimov N.V., Dantsig I.I., Matyukhina L.M., Kostina O.Y.


A case is reported of an old female patient with exogenic allergic alveolitis which was first diagnosed as pneumonia progressing in the presence of long-term and intensive antibiotic treatment. Detailed analysis of the case history gave grounds for suspected drug-related exogenic allergic alveolitis. Discontinuation of antibiotics, administration of glucocorticoids and antiplatelet drugs led to recovery.
Terapevticheskii arkhiv. 2011;83(11):59-62
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Food allergy

Luzina E.V., Bogomolova I.K., Tereshchenko V.N., Luzina E.V., Bogomolova I.K., Tereschenko V.N.


Food allergy (FA) - a condition of high sensitivity to food products - is widely spread allergic disease treated by allergologists, gastroenterologists, dermatologists, physicians, pulmonologists. FA pathogenesis involves immunological mechanisms with participation of immunocompetent cells and production of IgE and IgG. Treatment aims at elimination of causative antigen. Proteins of cow milk, hen's eggs, cereals, fish, citrus fruit, nuts, tomatos are most common such antigens. It is especially important for infants. FA manifests with anaphylactic shock, oral allergic syndrome, respiratory symptoms, abdominal impairments. The digestive system is both a target and a course of FA formation. FA arises mostly because of defects of gastrointestinal immune system, inability to synthetize IgA in adequate quantity while IgA has protective properties. Therefore, FA treatment should include probiotics, cytoprotectors, enzymes, sorbents. Atopic dermatitis, one of FA manifestations, is treated with non-hormonal drugs containing lipids, urea, topic inhibitors of calcinevrin. On demand, topic glucocorticosteroids, sometimes in combination with antimicrobial and antifungal drugs are added. Multidisciplinary approach to FA problem gives positive results.
Terapevticheskii arkhiv. 2011;83(11):62-66
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Antiretrovirus drugs impair kidneys in HIV-infection

Yushchuk N.D., Volgina G.V., Tomilina N.A., Gadzhikulieva M.M., Yuschuk N.D., Volgina G.V., Tomilina N.A., Gadzhikulieva M.M.


Renal damage in HIV infection may result from direct action of HIV and from other causes including nephrotoxic action of medicines. HIV-infected patients receive a wide spectrum of medicines and can be placed in a risk group of drug-induced damage to the kidneys. Risk of nephrotoxicity should be considered in administration of antiretrovirus drugs in HIV patients. Strategy of preventive measures in relation to pharmacological harm to the kidneys consists in early detection of patients with high risk and correction of modifiable risk factors.
Terapevticheskii arkhiv. 2011;83(11):66-70
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Experience with rituximab treatment (monoclonal antibodies to B-lymphocyte CD20 receptors) of Wegener's granulematosis patients with renal impairment

Novikov P.I., Krivosheev O.G., Semenkova E.N., Novikov P.I., Krivosheev O.G., Semenkova E.N.


Aim. To assess efficacy of rituximab in patients suffering from Wegener's granulematosis (WG) with renal disease. Material and methods. We analysed clinical laboratory data from 9 WG patients with renal disease treated with rituximab in E.M. Tareev clinic. Results. The treatment led to a complete remission in 7 (77.8%) patients, a partial remission - in 2 (22.2%) patients. Vasculitis activity regressed including renal damage (a decrease of 24 h proteinurea, enhanced glomerular filtration rate). A prednisolone dose decreased from 38.3 to 10 mg/day (to month 6) and to 7.5 mg/day (to month 12). Non-selective cytostatic drugs were discontinued in all the patients. Recurrences occurred in 3 (33.3%) patients, one with lethal outcome after 6 months of rituximab administration, in two cases one more course of rituximab produced another complete remission. Serious side effects were absent. Conclusion. Rituximab demonstrated high efficacy in the treatment of WG with renal affection resistant to standard therapy, in multiple side effects of standard immunosuppressive therapy and recurrent course. Rituximab help overcome steroid dependence even at late stages of the disease.
Terapevticheskii arkhiv. 2011;83(11):70-76
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From classificational medicine to clinical medicine (the end of the XVIII century to 1870s). Communication 3. The second stage of clinical medicine development: introduction of methods of laboratory experiment and chemical analysis

Stochik A.M., Zatravkin S.N., Stochik A.M., Zatravkin S.N.


The article concerns the end stage of clinical medicine establishment covering the period from early 1840s to the middle 1870s of the XIX century. Basic scientific achievements related to introduction into practical medicine of the methods of laboratory experiment and chemical analysis are reviewed.
Terapevticheskii arkhiv. 2011;83(11):76-80
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E. E. Gogin

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Terapevticheskii arkhiv. 2011;83(11):80-80
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