Rickettsioses and Rickettsial diseases in Croatia

Aim: To review the current state of knowledge concerning rickettsiae and rickettsioses in Croatia. Methods: The PubMed database was searched from 1991 to 2018 by combining the words “rickettsia,” “rickettsiosis”, “and “Croatia”. Results: Since 1969, Croatia appears to be free of epidemic typhus (ET) caused by Rickettsia prowazekii and the last case of Brill-Zinsser disease was recorded in 2008 (a total of 174 cases from 1957 to 2018). Mediterranean spotted fever (MSF) caused by R. conorii is the most frequent human rickettsial infection in Croatia, followed by murine typhus caused by R. typhi. Human cases of MSF and murine typhus have been predominantly observed along the eastern Adriatic coast from Zadar to Dubrovnik and between Zadar and Split, respectively. R. akari, etiologic agent of rickettsialpox, was isolated from the blood of a patient diagnosed with MSF in Zadar, but no cases of rickettsialpox were reported. Conclusion: Rickettsiae and rickettsial diseases continue to be present in Croatia. So, it is very challenging for a general practitioner (GP) to recognize the clinical symptoms of rickettsial diseases. At hospital admission, physicians should also include rickettsioses in the differential diagnosis for sepsis syndrome, especially at the first examination of the patients with rash

Q-vrućica: klinička, laboratorijska, epidemiološka i terapijska obilježja

Q-vrućica je najčešća antropozoonoza u svijetu i u nas, obilježena endemskim i epidemijskim načinom održavanja i pojavljivanja. Uzročnik bolesti je Coxiella burnetii. Glavni prirodni rezervoari i izvori infekcije Coxiellom burnetii su ovce, koze i goveda, koji nakon infekcije izlučuju mikroorganizme u urinu, fecesu, mlijeku, posteljici, plodnim ovojima i plodnoj vodi. Udisanje infi ciranog aerosola glavni je put prijenosa C. burnetii. Klinički simptomi i znakovi izraženi su različitim zasebnim kliničkim sindromima kao akutna bolest s visokom temperaturom, upala pluća, endokarditis, hepatitis i drugi oblici. Potvrda kliničke dijagnoze temelji se na nalazima seroloških testova, izolaciji mikroorganizma i detekciji nukleinske kiseline polimeraznom lančanom reakcijom. Antibiotik izbora u liječenju akutne Q-vrućice (upala pluća) jest doksiciklin, alternativni lijekovi su azitromicin, ciprofl oksacin i rifampicin. Liječenje kroničnih oblika Q-vrućice provodi se kombinacijom antibiotika (doksiciklin, ciprofloksacin, rifampicin, pefl oksacin, ofl oksacin, trimetoprim-sulfametoksazol). U osoba izloženih infekciji C. burnetii (laboratorijsko osoblje, veterinari i radnici u klaonicama stoke) provodi se cijepljenje

Q Fever

Q-groznica je akutna, a u rijetkim slučajevima i kronična bolest i najčešća antropozoonoza, raširena diljem svijeta. Uzročnik Q-groznice je Coxiella burnetii, pleomorfni kokobacil obvezatnog unutarstaničnog smještaja, osnovne strukture stanične stijenke nalik onoj gram-negativnih bakterija. U nepovoljnim uvjetima C. burnetii održava se u obliku endospora, pokazuje veliku otpornost na utjecaje vanjske sredine. Iako je primarno prirodnožarišna zoonoza, ova se bolest otisnula iz svojih prirodnih žarišta, adaptirala se na domaće životinje, ovce i krave, u novije vrijeme i koze, koje su glavni izvor infekcije za ljude. U posteljici, plodnim ovojima i plodnoj vodi, u vrijeme okota životinje izbacuju velike količine mikroorganizama u vanjsku sredinu, a isparavanjem i sušenjem stvara se infi cirani aerosol, pripravan za širenje infekcije udisanjem (glavni način prijenosa infekcije sa životinja na ljude). Klinički simptomi i znakovi bolesti izraženi su različitim zasebnim kliničkim sindromima, kao akutnom bolešću s visokom temperaturom, upalom pluća, endokarditisom, hepatitisom, osteomijelitisom, infekcijom u imunokompromitiranih osoba, infekcijom dojenčadi, infekcijom s dominantnim neurološkim manifestacijama. Klinička slika, epidemiološka anamneza, rendgenski i rutinski laboratorijski nalazi imaju manje značenje u konačnom dijagnosticiranju infekcije C. burnetii u odnosu na serološke metode (mikroaglutinacija - MA, reakcija vezanja komplementa - RVK, mikroimunofl uorescentni test - m-IF i imunoenzimatski test - ELISA), izolaciju mikroorganizma ili detekciju nukleinske kiseline polimeraznom lančanom reakcijom (PCR). U liječenju Q-groznice antibiotici izbora su tetraciklini (doksiciklin), a alternativni i djelotvorni lijekovi su makrolidi (azitromicin) i kinoloni (ciprofl oksacin).Q fever is an acute, and rarely chronic, zoonotic disease. It is caused by Coxiella burnetii, an obligate intracellular, pleomorphic coccobacillus possessing a prototypic gram-negative bacterial cell wall structure. It survives unfavourable conditions in the form of endospores and is extremely resistant to environmental effects. Although Q fever was primarily a zoonotic disease affecting wild animals, it has adapted to domestic animals, i.e. sheep, cattle and recently goats, which are the main sources of infection for humans. During birthing the organisms are shed in high numbers within the amniotic fl uids and the placenta. People are usually infected by inhaling the infected aerosol (the most common mode of transmission of infection from animals to people). Clinical symptoms are manifested in various clinical syndromes, such as acute disease with elevated temperature, pneumonia, endocarditis, hepatitis, osteomyelitis, infection in immunocompromised patients, infection in infants, infection with dominant neurological manifestations. Clinical picture, epidemiological anamnesis, x-rays and laboratory tests are less important in the fi nal diagnosis of Coxiella burnetii infection than serologic methods (microagglutination - MA, complement fi xation test - CFT, microimmunofl uorescence test - m-IF, immunoenzymatic test - ELISA), isolation of microorganisms or detection of nucleic acid by polymerase chain reaction (PCR). Tetracyclines (doxycycline) are the antibiotics of choice in the treatment of Q fever. Macrolides (azithromycin) and quinolones (ciprofl oxacin) have also proven effi cient

Zadarsko zdravstvo u razdoblju od završetka Drugog svjetskog rata do danas (1945. – 2008.)

U ovom radu, a na temelju zapisa u stručnim časopisima, monografijama i knjigama, prikazujemo razvitak zadarskog zdravstva u razdoblju od završetka Drugog svjetskog rata do danas (1945. – 2008.). Reorganizacija zdravstvene službe iz ratnih na minimalne mirnodopske uvjete rada počela je stvaranjem stacionara u Bokanjcu 1944. i otvaranjem bolnice 1945. godine. Nova organizacija na pružanju zdravstvene zaštite sastojala se u uspostavljanju zdravstvenih stanica i ambulanti, organizaciji ljekarničke djelatnosti, održavanju zdravstvenih tečajeva. Otvaranjem Gradsko-kotarske poliklinike 1948. ujedinjena je izvanbolnička zdravstvena djelatnost, a otvaranjem Doma zdravlja 1952. godine ujedinjena je kurativna i preventivna izvanbolnička djelatnost. Medicinski centar u Zadru, kao institucionalizirani oblik integralne zdravstvene zaštite, formiran je 1962. godine. Duševna bolnica u Zemuniku, kao Psihijatrijski odjel Zadarske bolnice, otvorena je 1949., a Psihijatrijska bolnica Ugljan, kao azil za duševne bolesnike, 1955. godine. Djelatnost opskrbe lijekovima provodi Ljekarna Zadar od 1962. godine. Zavod za zaštitu zdravlja, kao ustanova za potpunu i cjelovitu preventivnu i socijalno-medicinsku zdravstvenu zaštitu, formiran je 1984. godine. Medicinski centar Zadar razdvojen je 1993. godine na Opću bolnicu i Dom zdravlja. Stručna knjižnica Opće bolnice Zadar, stručni časopis Medica Jadertina, Znanstvena jedinica i Hrvatski liječnički zbor – podružnica Zadar omogućili su uvjete za stručni i znanstveni rad zdravstvenih djelatnika. Tijekom Domovinskog rata (1991. – 1995.) zdravstvenu skrb ranjenicima i bolesnicima pružali su djelatnici u Općoj bolnici, gradskim i terenskim ambulantama i zdravstveni djelatnici angažirani u pokretnim medicinskim ekipama uključenim u borbene postrojbe Zbora narodne garde, Hrvatske vojske i Ministarstva unutarnjih poslova. U razdoblju od završetka Drugog svjetskog rata do danas zadarsko zdravstvo je u stalnom usponu u stvaranju stručnih i znanstvenih kadrova i tehničkoj opremljenosti

Descendentni nekrotični medijastinitis kao posljedica retrofaringealnog apscesa

Descending necrotizing mediastinitis secondary to a nontraumatic retropharyngeal abscess is very rare. This form of mediastinitis in the era of potent antibiotics often ends up with lethal outcome. It usually occurs in immunocompromised patients and requires intensive multidisciplinary treatment approach. We report a case of nontraumatic retropharyngeal abscess complicated by descending necrotizing mediastinitis in a 70-year-old man with insulin dependent diabetes mellitus. The patient was admitted to our hospital after clinical and radiological diagnosis of retropharyngeal abscess. During treatment for retropharyngeal abscess with antibiotic therapy and transoral incision, the patient showed mild clinical improvement but his condition suddenly aggravated on day 4 of hospital stay. He had high fever, chest pain with tachypnea, tachycardia, hypotension, and showed signs of occasional disorientation. Emergency computed tomography (CT) scan of the neck and thorax showed inflammation in the retropharyngeal space, as well as thickening of the upper posterior mediastinum fascia with the presence of air. Emergency surgery including cervicotomy and drainage of the retropharyngeal space and posterior mediastinum was performed. The patient promptly recovered with improvement of the clinical status and laboratory findings. After 16 days of treatment he was discharged from the hospital in good condition. Descending necrotizing mediastinitis can be a serious and life threatening complication of deep neck infection if the diagnosis is not quickly established. Besides inevitable application of antimicrobial drugs, good drainage of the mediastinum is necessary. We believe that transcervical approach can achieve high-quality drainage of the upper mediastinum, especially if it is done timely as in this case. Its efficacy can be verified by intensive monitoring of the patient clinical condition, by CT scan of the thorax, and by laboratory tests. In the case of inefficacy of this type of drainage, subsequently some other, more aggressive transthoracic methods of drainage can be done.Descendentni nekrotični medijastinitis uzrokovan netraumatskim retrofaringealnim apscesom je jako rijedak. Ovaj tip medijastinitisa i u eri jakih antimikrobnih lijekova često završava smrtnim ishodom. Obično se javlja kod imunokompromitiranih bolesnika i zahtijeva intenzivni multidisciplinarni pristup liječenja. Prikazuje se slučaj netraumatskog retrofaringealnog apscesa i njegove komplikacije, descendentnog nekrotičnog medijastinitisa, u 70-godišnjeg muškarca s dijabetesom ovisnim o inzulinu. Bolesnik je primljen na bolničko liječenje nakon klinički i radiografski postavljene dijagnoze retrofaringealnog apscesa. Tijekom liječenja retrofaringealnog apscesa antimikrobnim lijekovima i transoralnom incizijom, uz kratkotrajno kliničko poboljšanje, četvrtog dana liječenja nastupilo je pogoršanje općeg stanja bolesnika. Postao je opet visoko febrilan, tahipneičan s bolovima u prsima, tahikardičan uz hipotenziju te je pokazivao znakove dezorijentiranosti. Kompjutorska tomografija (CT) vrata i toraksa pokazala je i dalje prisutnu upalu retrofaringealnog prostora uz zadebljanje fascijalnih prostora gornjega stražnjeg medijastinuma uz prisutnost zraka. Napravljen je hitan kirurški zahvat u smislu cervikotomije i drenaže retrofaringealnog prostora i medijastinuma. Stanje bolesnika se ubrzo popravilo u kliničkom smislu i laboratorijskim nalazima te je 16. dana liječenja otpušten na kućnu njegu u dobrom općem stanju. Descendentni nekrotični medijastinitis je ozbiljna komplikacija dubokih upala vrata i predstavlja opasnost za život bolesnika, naročito ako se dijagnoza ne postavi rano. Uz primjenu antimikrobnih lijekova osobito je važna visoko kvalitetna drenaža medijastinuma, pogotovo ako je napravljena pravodobno, kao u ovom slučaju. Njenu učinkovitost se može procijeniti pojačanim praćenjem kliničkog stanja bolesnika, primjenom CT toraksa i laboratorijskim testovima. U slučaju kad ovaj tip drenaže nije učinkovit moguće je uvijek napraviti mnogo agresivnije transtorakalne metode drenaže

Climate changes and rickettsioses

Cilj ovoga rada je prikazati suvremena saznanja i spoznaje o utjecaju klimatskih promjena na prirodu rikecija i rikecioza. Izolacija i identifikacija »novih« patogenih rikecija ostvarena je primjenom suvremenih dijagnostičkih testova. Danas je poznato dvadesetak patogenih rikecija, od kojih je njih 13 prepoznato tek proteklih dvadesetak godina. U tom razdoblju zabilježene su nove rikecijske bolesti, raširenost pojedinih rikecioza izvan poznatih endemičnih područja i ponovno epidemijsko javljanje već poznatih rikecioza. Udio utjecaja klimatskih promjena u epidemiologiji i kliničkom spektru rikecioza djelomično je razjašnjen i procjenjen, kao i udio čimbenika koji pripadaju rikecijskim domaćinima, vektorima ili samim rikecijama. Novija istraživanja potvrdila su značenje klimatskih utjecaja, osobito na brojčanost i raširenost R. sanguineusa, vektora R. conorii, uzročnika mediteranske pjegave groznice. Osim prepoznavanja novih rikecija i rikecioza bilježe se i nova saznanja o rikecijskim vektorima, širokom spektru kliničkih simptoma i znakova bolesti i javljanju bolesti, osobito mediteranske pjegave groznice, tijekom cijele godine, a ne samo sezonski (proljeće, ljeto). Pojavljivanje rikecioza, osobito rikecijskih pjegavih vrućica, u različitim područjima svijeta, a izvan prijašnjih endemskih područja, sve češća pojava rikecioza u izvansezonsko doba, širok spektar kliničkih simptoma i znakova bolesti, kao i pojava »novih« patogenih rikecija, upućuju na daljnje proučavanje klimatskih i drugih utjecaja na prirodu rikecija i rikecioza.The rickettsiae are ancient microorganisms that survived as intracellular bacteria in arthropods (ticks, mite) for thousands of years. There are several reasons why rickettsial diseases present an important health care problem. Their significance has been unjustly underestimated, especially after a decrease in the epidemologic occurrence of classic typhus. According to the World Health Organisation, typhus today occurs in smaller or larger epidemics in many endemic areas throughout the world and presents a constant threat for human health and life. There is an increasing number of records on new rickettsioses occurring or new areas of their distribution. In the last fifteen years, there has been a significant increase in the incidence of rickettsioses in endemic areas, a wide clinical spectrum of disease has been recorded, severe types and lethal outcomes of disease described, molecular investigations have introduced changes in rickettsiae taxonomy, a significant number of »new« pathogens has been discovered, new knowledge about rickettsiae and rickettsial diseases has been acquired. Thus, rickettsioses today account for diseases caused by rickettsiae from three separate genuses. Rickettsiae from the rickettsia genus cause rickettsioses from the spotted fever and typhoid group, rickettsia from the orientia tsutsugamush genus is the cause of scrub typhus, and rickettsiae from the ehrlichiae genus cause human ehrlichioses, Ehrlichia chaffeensis is the cause of human monocyte ehrlichiosis and Anaplasma phagocytophilum is the pathogen of human granulocyte anaplasmosis (known also as human granulocytic ehrlichiosis). For years, rickettsial diseases have not been considered important in travel medicine, and only rare clinical descriptions were mentioned, such as travelers′ disease. However, in the last ten years, in accordance with an increase and spread of ecotourism and tourists traveling to uninhabited areas, we record an increase in the incidence of spotted fever and other rickettsial diseases in travelers (tourists) that resided in endemic areas, especially in the countries of southern Europe, Africa and Asia. Intensified international travel and tourism have made geographical limitation of rickettsial diseases to endemic areas with moderate and tropical climate only fictive. Namely, residing in these areas creates a possibility for »importing« the disease, which presents a great difficulty for physicians, especially those without experience with rickettsioses, in clinical recognition of the disease. It is very dangerous to consider rickettsioses and rickettsial spotted fevers as self-healing diseases, as it was the case until recently. Mediterranean spotted fever, geographically most widespread rickettsiosis, can endanger human life, based on the manifestation of severe clinical forms of disease (acute renal failure, various neurological manifestations, peripheral gangrene). These severe clinical forms, with mortality rate ranging from 1,4 to 5,6 %, are more frequent among patients with Rocky Mountain spotted fever. Severe clinical forms of Mediterranean spotted fever, and one lethal outcome, have been recorded in our patients as well. Today, 20 pathogenic rickettsiae are known, 13 of which have been recognized in the last twenty years. It is still unclear whether recognizing newly discovered pathogenic rickettsiae is the result of improved diagnostics or changes in factors that belong to rickettsial hosts, vectors or rickettsiae themselves. Namely, some among these 20 pathogenic rickettsiae have been considered nonpathogenic or have not been registered yet. The role of abiotic factors is also unclear, especially geographic distribution and seasonal occurrence. Therefore, the opinion that certain rickettsioses are widespread only in a particular continent or that certain vectors are specific for certain rickettsiae, has changed, and more and more information supports the idea that various types of ticks and fleas are vectors of one or more rickettsiae. The question remains whether the affinity of certain ticks towards their host is changing, especially if such a change is the consequence of climate changes (rainfall, floods, droughts, global warming). The occurrence of rickettsioses, especially rickettsial spotted fevers, in various areas of the world, outside previous endemic regions, and the manifestation of newly discovered pathogenic rickettsiae demand further investigations of the impact of climate on the nature of rickettsiae and rickettsioses

Epidemiologic characteristics with injection drug users in Zadar County

U našem istraživanju analizirali smo, primjenom upitnika iz Pompidou obrasca, deskriptivna epidemiološka obilježja zabilježena u medicinskoj dokumentaciji u 327 intravenskih ovisnika u Centru za prevenciju i izvanbolničko liječenje bolesti ovisnosti u Zadru. Od ukupnog broja ispitanika većina je muškog spola (273; 83,4%), a omjer među spolovima je 5 muškaraca:1 žena. Ukupno najveći broj ispitanika nalazi se u dobnoj skupini od 21 do 25 godina (99; 30,3%), većina njih je (276; 84,4%) stekla cjelovito ili djelomično srednjoškolsko obrazovanje, živi s primarnom obitelji (200; 61,2%), prvo su kažnjivo djelo počinili nakon što su počeli uzimati teške droge (161; 49,2%), a manjina njih je cijepljena protiv B hepatitisa (49; 15%). Za problem ovisnosti najčešće prvi saznaju članovi obitelji (51,4%), većina roditelja ovisnika je u braku (209; 63,9%) i sazna da su njihova djeca ovisnici nakon 2-4 i više godina (53,8%). Većina roditelja ovisnika ima prosječan materijalni status (150; 55%) i srednjoškolsko obrazovanje (201; 61,5%). Model ranog otkrivanja bolesti ovisnosti i smanjenja broja teških ovisnika označava obitelj kao kjučno mjesto gdje se provode sve mjere primarne i sekundarne prevencije bolesti ovisnosti, uz povezanost i suradnju državnih ustanova u kojima se provode tercijarne mjere s ciljem rehabilitacije i resocijalizacije ovisnika.In our research we have used the Pompidou from to analyze the descriptive epidemiologic features reported in the medical documents of 327 injection drug users in the Center for Prevention and Out-Patient Treatment of Addicts in Zadar. Most of the examinees were of male gender (273; 83,4%) and the gender ratio was 5 men: 1 woman. The greatest number oexaminees belongs to the 21-25 age group (99; 30,3%), most of them have partly or entirely (276; 84,4%) finished secondary school, living with their primary family (200; 61,2%), have vaccinated against hepatitis B (49; 15%). Members of the family are most often the first to find out of the addiction (51,4%) most of the addicts parents are married (209; 63,9%) and find out of their children\u27s addiction after 2-4 years and more (53,8%). Most of the addicts parents are of average material status (150; 55%), and have a secondary school education (201; 61,5%). The early addiction discovery model and the number of addicts reduction indicates the family as the key place to enforce all primary and secondary measures of drug addiction prevention, connected with the cooperation with goverment institutions where tertiary measures take place in the aim of addicts rehabilitation and resocialization

The Effect of Propofol and Fentanyl as Compared with Sevoflurane on Postoperative Vomiting in Children after Adenotonsillectomy

Postoperative vomiting (PV) after adenotonsillectomy in children is a common problem with an incidence as high as 40–80%. Only few studies in the recent literature compared the effect of different anesthetic techniques concerning PV in children. The aim of this study was to compare the incidence of PV in two groups of children who underwent two different general anesthesia techniques in order to determine what type of anesthetic technique is more related to less PV. The clinical trial included 50 children (physical status ASA I, 3–12 years old) divided into 2 groups and monitored for PV 24 hours following the surgery. Group one (G1) consisted of 25 children who underwent general anesthesia with gas mixture 60% nitrous oxide and 40% oxygen and anesthetic propofol, opioid fentanyl and muscle relaxant vecuronium intravenously and group two (G2) included 25 children to whom volatile anesthesia with sevoflurane in the same gas mixture was given. Demographic characteristics (gender, age, weight, history of motion sickness and earlier PV) as well as surgical data (length of surgery and anesthesia, intraoperative blood loss) were recorded. There were no significant differences considering demographic characteristics and surgical data between the investigated groups. The incidence of PV was relatively low 3 children (12%) in G1 group and 5 children (20%) in G2 group. Statistically there was no significant difference between the groups regarding the incidence of PV and both anesthetic techniques can be used equally safe regarded to PV