Vol 90, No 11 (2018)
- Year: 2018
- Published: 15.11.2018
- Articles: 20
- URL: https://ter-arkhiv.ru/0040-3660/issue/view/1860
Editorial article
Problems of clinical diagnosis and treatment of P. falciparum malaria in Russian Federation
Abstract
Aim. To study the causes of falciparum malaria deaths in Russian Federation and to optimize therapy for severe forms of the disease. Materials and methods. The analysis of falciparum malaria cases with deaths recorded in Russian Federation from 2013 to 2017 was conducted. The results of optimization of pathogenetic therapy of severe forms of falciparum malaria for the prevention of adverse outcomes in the intensive care unit of the Infectious Clinical Hospital №2 of Moscow in 44 patients with severe course are presented. Treatment, clinical laboratory and instrumental investigations were carried out in accordance with our intensive care protocol, which took into account the current WHO recommendations. Results. From 2013 to 2017 there were nine deaths from falciparum malaria reported in patients from African countries (6) and India (3). In Russia, due to the lack of effective drugs of artemisinin group, quinine with tetracycline or doxycycline is used for etiotropic therapy of patients with complicated form of falciparum malaria. In the management of such patients, the basis for treatment was the prevention of ischemic, reperfusion injuries of organs and hemorrhagic complications. In the infectious clinical hospital №2 of Moscow, since 2007, the intensive care unit has developed and tested a protocol for intensive therapy in patients with severe and complicated forms of falciparum malaria, including preventive methods of extracorporeal hemocorrection with prolonged veno-venous hemodiafiltration therapy and plasmapheresis, as a result of which the mortality rate decreased from 84 to 6.8% Conclusion. The country's lack of anti-malarial drugs, the insufficient awareness of the population about the risk of infection and measures to prevent malaria, late referral of cases for medical care and errors of clinical diagnosis and treatment annually lead to fatal outcomes. In such situation, the experience of optimizing the treatment of severe falciparum malaria is particularly useful, allowing decreasing the mortality.
Terapevticheskii arkhiv. 2018;90(11):4-8
4-8
Development of opportunistic lesions in patients with HIV infection in the absence of pronounced immunodeficiency
Abstract
Research objective. Statistical data concerning patients with opportunistic infections depending on parameters of immunity and the description of a number of clinical cases of development of opportunistic lesions in patients with HIV infection in the absence of the expressed immunodeficiency. Materials and methods. Medical records of the patients with HIV infection hospitalized in 2012-2015 in the Infectious Diseases Clinical Hospital No. 2 of Moscow, and the clinical cases of patients with development of opportunistic lesions with satisfactory indicators of the immune status. Results. The distribution of patients with HIV infection who had opportunistic infections, depending on the number of CD4+ lymphocytes at the time of development of the disease revealed a significant group of patients with a sufficiently large number of CD4+ cells. Statistical data on the development of various opportunistic lesions with different parameters of the immune status are presented. The authors describe a number of relevant clinical cases. Discussion. The possible causes of the development of opportunistic diseases and their recurrence in patients with HIV infection with a satisfactory amount of CD4+ lymphocytes are discussed. In the pathogenesis of this phenomenon are important not only quantitative but also qualitative parameters of immunity, as well as the characteristics of the causative agents of opportunistic lesions.
Terapevticheskii arkhiv. 2018;90(11):9-12
9-12
Opportunistic diseases in patients with HIV infection in the intensive care unit
Abstract
The aim of the study was to analyze the incidence and prevalence of opportunistic diseases and comorbidities in patients admitted in the intensive care unit. Materials and methods. A specialized intensive care unit (ICU) for patients with severe HIV infection was set up in 2014 at the infectious diseases 2nd state hospital Moscow. It provides intensive care and treatments for HIV patients with severe co-morbidities and opportunistic infections. Retrospective analysis of medical records from 2014-2016 was carried out. Also carried out was a comparative study of the most common presentation of secondary diseases with available data of HIV patients in Russia from 1993-1997. Results. The number of patients treated increased from 455 to 852, and the death rate in the department decreased from 64.8 to 50.2% since it began operating. The opportunistic infections noted were cytomegalovirus, pneumocystis pneumonia, esophageal candidiasis, tuberculosis and toxoplasmosis of the brain. The most common comorbidities were chronic hepatitis C and mixed form of chronic hepatitis with cirrhosis complications. Despite the vast diagnostic possibilities, bacterial pneumonia and encephalitis of unknown origin significantly occurred. Comparative study of secondary disease since the early 1990s revealed a significant increase in cerebral toxoplasmosis (from 1.7 to 10.4%), pneumocystis pneumonia (from 5.2 to 16.0%) and encephalitis of unspecified etiology (from 13.8 to 39.4%) Conclusion. Disease severity among HIV patients is increasing. CMV and pneumocystis pneumonia were predominant opportunistic diseases. There were significant changes in the presentation of secondary diseases compared to data from 1993-1997.
Terapevticheskii arkhiv. 2018;90(11):13-17
13-17
Clinical, Virusological and Immunological characteristics of hospitalised HIV-infected patients
Abstract
Aim. The primary objective of this study was to describe clinical, virusological and immunological characteristics of hospitalised HIV-infected patients, who had different stages of the disease. Materials and methods. This study was conducted at Moscow Infectious Diseases Hospital №2 in 2012-2015. We have clinically observed 5485 HIV-infected patientsand studied their clinical histories [age: 25-45 (87%), men - 3998 (72.9%), women - 1487 (27.1%)]. 593 (10.8%) have died. We have tested plasma and liquor HIV RNA viral load, immune status, number of viral DNA copies in blood, liquor, lavage, pleural fluid, large intestinal and esophagus biopsies and other materials. Statistica v. 10.0 and SPSS v. 20 were used for statistical analysis. Results and conclusion. Clinical state of HIV-infected hospitalised patients has been described and the results of quantitive determination of HIV RNA in blood and liquor, absolute and relative CD4+ and CD8+ T-lymphocytes concentrations and immunoregulatory index in patients in various disease stages, including patients on antiretroviral therapy (ART) have been presented. Statistically significant correlation between blood and liquor HIV RNA load as well as between viral load and cellular immune markers in hospitalised HIV-infected patients has been found.
Terapevticheskii arkhiv. 2018;90(11):18-23
18-23
The role of systemic inflammation in the pathogenesis of insulin resistance and metabolic syndrome in patients with chronic hepatitis C
Abstract
The systemic inflammatory response plays a key role in the development of atherosclerosis, insulin resistance (IR) and diabetes mellitus 2-type (diabetes mellitus). IR in patients with chronic hepatitis C (CHC) is considered as a possible factor in the progression of fibrosis, a predictor of the development of DM T2 and a component of the metabolic syndrome. The use of biomarkers of non-specific inflammation can be a valuable tool for assessing the risks of IR and cardiovascular diseases in patients with chronic hepatitis C. Aim of the study. To determine the role of nonspecific inflammation in the formation of IR and metabolic syndrome in patients with chronic hepatitis C. Materials and methods. The study included 205 patients with CHC aged 18 to 69 years. Patients with CHC are randomized into two groups depending on the presence of IR: group 1 - patients with a HOMA index ≥2.77, which corresponded to IR (n=110); group 2 (n=95). The levels of serum iron, C-reactive protein (CRP), serum ferritin and adipose tissue hormones [leptin, resistin, adiponectin and tumor necrosis factor-α (TNF-α)] were additionally investigated. Results. At all stages of development of IR, nonspecific inflammation was detected (according to ferritin, CRP and serum iron), increasing with increasing HOMA index [Homeostasis Model of Assessment - Insulin Resistance (HOMA-IR)] (Matthews D., 1985), metabolic syndrome and its components. In the analysis of indicators in patients with chronic hepatitis C with a body mass index <25 kg/m2, conjugacy of IR with low-intensity inflammation, high viral load and hypersecretion of TNF-α was detected. Conclusion. Given the high predictor role of CRP indicators in predicting IR, it should be used as a surrogate screening marker of IR in patients with chronic hepatitis C and should be actively treated for violations.
Terapevticheskii arkhiv. 2018;90(11):24-31
24-31
Clostridium difficile in inflammatory bowel disease
Abstract
Aim. To study epidemiology and risk factors for Clostridium infection (CDI) associated with Clostridium difficile in patients with inflammatory bowel disease (IBD). Materials and methods. 1179 medical records were analyzed in a retrospective study of patients with IBD, of which 764 patients met the inclusion criteria. Patients were divided into 2 groups based on the presence of a preliminary diagnosis of CDI. Statistical analysis was carried out using Pearson Chi-square and two-sample t-test. Results. The incidence of CDI in patients with IBD was 17.3%, with the same prevalence in patients with Crohn's disease (CD) (n=53/40.1%) and ulcerative colitis (UC) (n=79/59.9%). The mean age of occurrence of CDI in patients with IBD was 37.8±12.9, 84.8% of infections were community-acquired and only 4.5% occurred in medical institutions. Only 21.2% of all patients with CDI had a history of antibiotic use, and 24.2% had previously used steroids. Long-term immunosuppressive therapy in patients with IBD has an impact on the development of CDI: among patients with CDI 45.5% long-term received azathioprine/6-mercaptopurine, in patients without IBD - 17.7% (p<0.001). 18% of patients with CDI had control of the disease with salicylate therapy, while 62% of patients without CDI achieved remission by taking salicylates (p<0.05). Conclusion. The prevalence of CDI in UC and CD is comparable (p=0.16). The study shows that patients with IBD are more sensitive to the development of CDI at a young age, while not having such traditional risk factors as recent hospitalization or antibiotic use. Patients with IBD with CDI in history often noted the ineffectiveness of therapy with salicylates, often require the assignment of biological therapy. IBD patients with CDI have a lower average albumin, and a higher activity of the inflammatory process.
Terapevticheskii arkhiv. 2018;90(11):32-36
32-36
Evaluation of lipid peroxidation processes in patients with chronic parenteral viral hepatitis and HIV co-infection depending on degree of inflammatory process activity in the liver
Abstract
The aim of the study. To evaluate of parameters of lipid peroxidation - antioxidant defense changes in women of fertile age with chronic viral hepatitis (CVH) and with HIV (human immunodeficiency virus) infection, depending on the degree of inflammatory process activity in the liver. Materials and methods. 99 women of reproductive age were examined, of them 44 patients with chronic parenteral viral hepatitis, 27 patients with HIV co-infection (HIV + hepatitis B and/or C) and 28 practically healthy women (control group). Results. Patients with CVH in combination with HIV-infection with the presence of minimal and low degree of inflammatory activity in comparison with patients with CVH-monoinfection had a higher content of lipid peroxidation products (an increase in the content of diene conjugates and ketodienes and conjugated trienes), reduced values of total antioxidant activity, superoxide dismutase activity, as well as the concentration of fat-soluble vitamins α-tocopherol and retinol. In the group with CVH and HIV with moderate and high degree of activity, similar, but even more pronounced changes in the system of lipid peroxidation were observed. Conclusion. The presence of co-infection - CVH in combination with HIV infection with minimal and low, as well as moderate and high inflammatory activity, is characterized by more intensive lipid peroxidation processes and a pronounced lack of antioxidant factors than with CVH-monoinfection.
Terapevticheskii arkhiv. 2018;90(11):37-43
37-43
The role of presepsin in the diagnosis and assessment of severity of sepsis and severe pneumonia
Abstract
The aim of this study was to evaluate marker of inflammation presepsin to improve diagnosis of severe pneumonia, sepsis. Materials and methods. 75 patients with pneumonia, sepsis, other inflammatory diseases aged from 17 to 78 years were examined. These patients have been investigated for the level of the presepsin. Presepsin level was quantified on immunohemilyuministsentny analyzer Pathfast (Mitsubishi Chemical Medience Corporation, Japan) in pg/ml. All patients had obtained an antibacterial therapy in other health care organizations before entering the hospital. Results. Presepsin at the general group of patients with pneumogenic sepsis was 3196.9±1202.16 pg/mL (n=14, x̅±m), with abdominal sepsis - 2506.7±448.32 pg/mL (n=28), with other inflammatory diseases - 671.6±124.55 pg/mL (n=11). Presepsin of patients with pneumogenic sepsis was 1125.3±240.59 pg/mL (n=3), presepsin of patients with severe pneumonia was - 362.6±76.29 pg/mL (n=13, p<0.05), non-severe pneumonia - 157.3±33.02 pg/mL (n=9, p<0.05). Conclusion. The high level of presepsin is an indication of an active infectious disease and reflects the severity of the pneumonia and development of sepsis. Keeping a high level against the backdrop of earlier presepsin ongoing antibiotic therapy is an indication of their lack of effectiveness. A significant variability of presepsin should be taken into account.
Terapevticheskii arkhiv. 2018;90(11):44-47
44-47
Clinical and interferon-modulating efficacy of a combination of rectal and topical dosage forms of interferon-α2b in acute respiratory infections
Abstract
The aim of the study was to evaluate the clinical and interferon-modulating efficacy of a combination of rectal and topical dosage forms of IFN-α2b with antioxidants in the treatment of acute respiratory infections (ARIs) in comparison with other variants of antiviral therapy. Materials and methods. A total of 90 servicemen aged 19.2±0.9 years with uncomplicated forms of ARI were hospitalized not later than 48 hours after the onset of the disease. Patients were randomized into 3 groups of 30 people each. In the first group, patients received rectal suppositories containing IFN-α2b (1 million IU) and antioxidants (alpha-tocopherol acetate and ascorbic acid) twice a day for 5 days. In the second group, patients received intranasally a gel formulation containing IFN-α2b (36 000 IU/1 g) and antioxidants 3 times a day in addition to the above suppositories. In the third group, patients were prescribed umifenovir (reference drug) at dose of 200 mg 4 times a day for 5 days. The dynamics of regression of clinical manifestations of ARI in different groups, changes in concentrations of IFN-α and IFN-γ in blood plasma, as well as spontaneous and induced production of these cytokines by blood cells ex vivo were evaluated. After that, the patients were observed for another 3 months to register repeated cases of hospitalization for ARI. Results. Marked tendency to accelerate the regression of symptoms of intoxication and fever was observed when intranasal dosage form of IFN-α2b was administered to patients receiving the rectal form of this cytokine. The combination of rectal and topical dosage forms of IFN-α2b with antioxidants was more effective than monotherapy with the rectal suppositories in preventing repeated hospitalization for ARI. The above combination caused the most complete correction of induced production of IFN-α by blood cells ex vivo at its initial deviation from the norm. Conclusion. The obtained data indicate the expediency of using the combination of rectal and topical dosage forms of IFN-α2b with antioxidants for treatment of ARI.
Terapevticheskii arkhiv. 2018;90(11):48-54
48-54
Efficacy of 13-valent pneumococcal conjugate vaccine in healthcare workers
Abstract
Aim. To establish the efficacy of 13-valent pneumococcal conjugate vaccine (PCV13) for healthcare workers protection from occupational acquired infection and impact of healthcare staff vaccination on the risk of transmission to patients. Materials and methods. Healthcare personnel (n=157 of whom 105 critical care department staff) and 1770 patients of that critical care department observed. Healthcare workers received PCV13. Infections caused by Str. pneumoniae, respiratory infections regardless of etiology, work absenteeism in healthcare workers during 12 month before and after vaccination assessed. In the same time monitoring of hospital-acquired infections in patients of critical care department performed. Statistical analysis was done using SPSS 24, relationships were assessed by rate ratio, Cox regression, logistic regression and Kaplan-Meier estimator. Results. Healthcare workers' vaccine coverage in critical care department was 97.2%. In healthcare personnel the rate of all pneumococcal infections, asymptomatic carriage of Str. pneumoniae and respiratory pneumococcal infections were decreased after vaccination by 2.1, 2.2 and 2.1 times accordingly. The rate of respiratory infections regardless of etiology was decreased by 30%, р<0.05. Cumulative percent of subjects without pneumococcal respiratory infections during 12 month was 87.9 before and 94.3 after vaccination, р=0.015. Work absenteeism due to respiratory infections was reduced. In patients of critical care department decreasing of all respiratory infections by 58%, pneumococcal respiratory infections by 66%, hospital acquired pneumonias by 46% were seen, р<0.05. Conclusions. Healthcare personnel vaccination with PCV 13 is effective in protection from occupational acquired pneumococcal respiratory infections and asymptomatic carriage and promotes decreasing of hospital acquired infections among patients.
Terapevticheskii arkhiv. 2018;90(11):55-61
55-61
Bilateral thalamic stroke in patient with patent foramen ovale and hereditary thrombophilia
Abstract
Patent foramen ovale and hereditary thrombophilia are both known risk factors for ischemic stroke. Artery of Percheron is a rare anatomical variant in which vast areas of the midbrain and thalamus have a single source of blood supply. This case report presents a 45-years old female patient with bilateral thalamic stroke due to Percheron artery occlusion, with a combination of hereditary thrombophilia and patent foramen ovale as the risk factors. Modern approaches to the diagnosis and secondary prevention of this pathology are also discussed herein.
Terapevticheskii arkhiv. 2018;90(11):62-66
62-66
Hepatic decompensation associated with an interferon-free antiviral therapy in patients with HCV-cirrhosis
Abstract
Today, there is no complete clarity about the pathogenetic mechanisms of the hepatic decompensation in patients with HCV-cirrhosis during the course of direct-acting antiviral (DAAs) therapy. The current article describes several clinical observations of decompensation (with the development of liver failure and portal hypertension) in cirrhotic patients during the course of DAAs-therapy of hepatitis C. The authors present contemporary views and their own assumptions about the possible mechanisms of the hepatic decompensation associated with DAAs-therapy in patients with liver cirrhosis.
Terapevticheskii arkhiv. 2018;90(11):67-73
67-73
The first experience of non-interferon therapy of HCV infection in patients with Wilson-Konovalov’s disease
Abstract
In the article we present three clinical observations demonstrating that HCV infection in patients with remission of Wilson disease causes an recrudescence of the disease, in one of the observations - decompensation of liver cirrhosis. In this study we first describe on the successful treatment of HCV infection with direct antiviral drugs in patients with Wilson disease. Establishment of all factors of liver damage and successful treatment (elimination of the virus, adequate lifelong medical treatment) allow to expect a favorable prognosis in patients with a combination of Wilson disease and HCV infection.
Terapevticheskii arkhiv. 2018;90(11):74-78
74-78
Case of thrombosis of the portal vein and its branches in a patient seropositive for Borrelia antigens
Abstract
Borreliosis after sucking ticks is an acute problem in the world. People do not go to doctors after that often, which leads to the development of various complications. Thrombosis of veins of various localization can be one of them. Thrombosis of the portal vein represents a significant problem too with high morbidity and mortality. The risk factors for splanchnic vein thrombosis include infections, but its relationship with borreliosis has not been studied. А 34-year-old man with chronic helicobacter-associated gastritis and gallstones was hospitalized due to development during the last 11 days of epigastric pain and fever to 38.7 °C after a picnic at the forest without a registered tick bite. The blood leukocytes were increased to 11.2*109/l, lymphocytes 70%, C-reactive protein 34.6 mg/l, procalcitonin 0.195 ng/ml. The multispiral computed tomography of the abdominal cavity revealed thrombosis of portal, lienalis and superior mesenteric veins. D-dimer was 1.98 mcg/ml, antithrombin III 75%. JACK2V617F, oncological, rheumatic, thrombophilia markers, blood and urine cultures were negative. A high concentration of anti-Borrelia burgdorferi IgM 62.2 U/ml and its increasing to 190 U/ml in dynamics was revealed at the immunofluorescence assay. Anti-Borrelia IgM to OspA, p31 and OspC, p25 were detected at the immunoblotting assay. Anticoagulation, doxycycline, detoxification therapy reduced pain and normalized temperature and inflammation markers. Vein thrombosis was not detected at the control tomography after 2 weeks. Despite that the combination of thrombosis and borreliosis is rare, it is necessary to screen for Borrelia antigens in patients with splanchnic vein thrombosis and fever.
Terapevticheskii arkhiv. 2018;90(11):79-89
79-89
The problem of diagnosis of generalized and focal forms of salmonellosis
Abstract
The article describes the clinical observation with an unfavorable outcome of the generalized form of salmonella infection caused by Salmonella typhimurium group B in a woman of 60 years without immunodeficiency, complicated by the development of multiple abscesses of the lower parts of abdominal cavity, probably of appendicular origin. In a short literary review, the pathogenetic mechanisms that contribute to the formation of generalized and extraintestinal forms of salmonella infection are discussed.
Terapevticheskii arkhiv. 2018;90(11):90-97
90-97
Abscess of the spleen in a patient with infectious endocarditis
Abstract
A patient with infective endocarditis (IE), complicated by the development of the abscess of the spleen, is described. The diagnosis of IE was verified several months after the onset of clinical symptoms (fever, hemorrhagic skin rashes, splenomegaly).The patient suspected hemorrhagic vasculitis and lymphoma of the spleen, which were not confirmed. With transesophageal echocardiography, vegetations on the aortic valve have been identified, and, according to CT, a spleen infarct with suspected abscess. A successful simultaneous operation was performed - aortic valve replacement and splenectomy. An abscess was found in the spleen. The patient is discharged in a satisfactory condition.
Terapevticheskii arkhiv. 2018;90(11):98-101
98-101
Case of iatrogenic botulism after botulinotherapy in clinical practice
Abstract
Injections of botulinum toxin are widely used in different medical fields, namely neurology, urology, stomatology, cosmetology, gastroenterology etc. Preparations of botulinum toxin type A (BTA) prevent the release of acetylcholine at the endings of motor nerves leading to the long-term muscle relaxation. It has been acknowledged that treatment with BTA has very good safety profile and tolerability. Extremely rare but severe complication of botulinotherapy (BT) is a condition, which is associated with generalized muscle Weakness, swallowing difficulty, respiratory arrest, and may lead to the lethal outcomes in the solitary cases. Such disorders, which present like botulism, are known as botulism-like syndrome and iatrogenic botulism. We report a clinical case of such complication in the paper. The probability of the development of such rare but severe complications necessitates certain awareness and vigilance among clinicians performing BT.
Terapevticheskii arkhiv. 2018;90(11):102-104
102-104
Pets in modern society: hidden threats
Abstract
The article discusses the problem of the role of pets as a source of zoonotic infections, representing a hidden threat to modern society. Since the content is now very popular at home, both traditional and exotic animals, it is necessary to develop an interdisciplinary program to control the spread of zoonotic infections and the risks of their infection with people. Since the problem lies in the intersection of several disciplines, joint efforts of doctors, veterinarians, health organizers and laboratory specialists are necessary.
Terapevticheskii arkhiv. 2018;90(11):105-111
105-111
Infection in the clinic of internal diseases
Abstract
In the modern clinic of internal diseases, the specific gravity of the infectious pathology, manifested by various clinical syndromes, is increasing. Infectious pathology is represented by diseases of the respiratory system, heart disease (infective endocarditis, cardioimplant infections, viral myocarditis), infectious arthropathies, extrahepatic manifestations of viral hepatitis, cytopenic syndromes, various manifestations of sepsis and some other conditions.In most cases, the diagnosis and management of such patients is the responsibility of the internist, who must be able to suspect the infection and carry out its verification. In the process of diagnostic search and management of patients, close interaction of the internist with a clinical microbiologist, clinical pharmacologist and other related specialists is necessary.
Terapevticheskii arkhiv. 2018;90(11):112-119
112-119
Akademik Andrey Ivanovich Vorob'ev (k 90-letiyu so dnya rozhdeniya)
Abstract
А.И. Воробьев является ведущим ученым в области фундаментальных и клинических проблем онкогематологии и радиационной медицины. Редакционная коллегия журнала «Терапевтический архив» и сотрудники Научного медицинского исследовательского центра гематологии Минздрава России искренне поздравляют Андрея Ивановича Воробьева с этим знаменательным юбилеем и желают здоровья, хорошего настроения и долгих лет жизни.
Terapevticheskii arkhiv. 2018;90(11):120
120