Marked improvement in survival among adult Croatian AIDS patients after the introduction of highly active antiretroviral treatment

We compared the survival of patients following the first AIDS event in Croatia from the period 1986-1996 to the period 1997-2000. A total of 72 (81.8%) out of 88 patients from 1986-1996 and 18 (32.1%) out of 56 from 1997-2000 died. Survival following the first AIDS-defining illness markedly improved in the period 1997-2000 compared to the period 1986-1996 (adjusted Hazard Ratio (HR) for patients surviving more than 6 months: 0.11, 95% confidence interval (95% CI) = 0.04-0.29). A CD4+ cell count of < 100 x 10(6)/L was an independent risk factor for patients surviving up to 2 years (adjusted HR = 1.96, 95% CI = 1.1-3.43, p = 0.02). Patients with tuberculosis or fungal infections had a longer survival when compared to other diagnosis (adjusted HR = 0.53, 95% CI = 0.32-0.90, p = 0.01). However, despite dramatic survival benefit of combination antiretroviral therapy, mortality at six months following the first AIDS event was similar in the two study periods and the one-year probability of death was still substantial (27.2%) in the period 1997-2000

Evaluation of Periodontal Status in HIV Infected Persons in Croatia

A number of periodontal changes have been associated with human immunodeficiency virus (HIV) infection, however our knowledge of the epidemiology, microbiology, host response and natural history of these conditions remains limited. Therefore, the aim of our study was the assessment of possible differences in periodontal status of HIV infected subjects when compared with healthy controls matched for age, gender and smoking habit in Croatian population. Assessment included measurement of plaque accumulation using aproximal plaque index, measurement of gingival inflammation by use of sulcus bleeding index, pocket depth, gingival recession as well as the number of decayed, missing and filled teeth in 25 HIV infected subjects (age range 22–61, X=40.8 years) in comparison with 25 healthy controls (age range 20–62, X=40.9 years). Statistical analysis was performed by use of descriptive statistics and Mann-Whitney U test showed significantly increased level of inflammation of the marginal gingiva in HIV infected subjects when compared to the controls (p<0.002). Significantly increased mean values of periodontal pockets (p<0.002) and the deepest periodontal pocket (p<0.003) were also observed when HIV infected subjects were compared to the healthy controls. In HIV infected subjects there was significant increase in the number of decayed, missing and decrease in the number of filled teeth (p<0.002; p<0.002; p<0.009, respectively). The results of this study once again highlight the need for more prevalent periodontal check-ups and treatments in HIV infected subjects

Progressive multifocal leukoencephalopathy (PML) in HIV-infected patients – a case report and review of patients treated at the University Hospital for Infectious Diseases in Zagreb

U četrdesetogodišnje bolesnice s postupnim i progresivnim razvojem neuroloških simptoma dijagnosticirana je HIV-bolest uz veoma izraženu imunodeficijenciju. Na temelju neuroloških simptoma (motorni deficiti, kognitivni poremećaji, poremećaji govora, vida, tonusa muskulature, smetnje koordinacije) te slikovnih radioneuroloških tehnika postavljena je klinička dijagnoza progresivne multifokalne leukoencefalopatije (PML). Naknadno je dijagnoza PML potvrđena pozitivnim nalazom reakcije lančane polimeraze (PCR) na JC virus u likvoru. Bolesnica je liječena antiretrovirusnim lijekovima uz ostalu simptomatsku i suportivnu terapiju. Unatoč određenom poboljšanju laboratorijskih parametara stečene imunodeficijencije na provedeno liječenje tijekom pet mjeseci bolest je nezadrživo napredovala do smrtnog ishoda. Do sada je u 20-godišnjem razdoblju u našoj Klinici liječeno ukupno 11 bolesnika s HIV-bolešću u kojih je na temelju kliničko-neuroloških manifestacija i neuroradioloških pretraga postavljena dijagnoza PML. Detalji su prikazani u tablici 2. U spomenutom slučaju po prvi put je u Hrvatskoj etiološka dijagnoza potvrđena dokazom JC virusa u cerebrospinalnom likvoru.HIV-infection with advanced immunodeficiency was diagnosed in a forty-year-old female patient with gradual and progressive development of neurological symptoms. Based on neurological symptoms (cognitive and motor deficits, speech, vision and muscular tonus disorders, coordination disturbances) as well as neuroradiological imaging, progressive multifocal leukoencephalopathy (PML) was diagnosed. Subsequently, the diagnosis of PML was confirmed with positive cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for JC virus. The patient was treated with antiretroviral drugs together with other symptomatic and supportive therapy. Despite somewhat improved laboratory parameters of acquired immunodeficiency after five-month therapy, the disease continued to progress and resulted in fatal outcome. In the last 20 years, altogether 11 HIV-infected patients were diagnosed with PML in our hospital based on clinical/neurological manifestations and neuroradiologic imaging findings. The details are presented in Table 2. In described case, for the first time in Croatia, the etiological diagnosis was confirmed with JC virus detection in the CSF

Typhoid form of tularemia: a case report

Tularemija je akutna, febrilna, granulomatozna zoonoza, primarno bolest glodavaca. Na čovjeka se prenosi direktnim kontaktom s bolesnom životinjom, ugrizom životinje ili insekta, ingestijom zaraženog mesa, vodom ili inhalacijom aerosola s inficirane životinje odnosno prašine. Način prijenosa određuje i razvoj kliničkih manifestacija ove zoonoze. Četrdesettrogodišnji bolesnik iz Zagreba zaprimljen je u Kliniku za infektivne bolesti devetog dana bolesti koja se očitovala remitentnim febrilitetom bez vodećeg simptoma. Zbog vrućice nejasnog uzroka bolesnik je uz simptomatsku terapiju liječen empirijski najprije koamoksiklavom parenteralno, a potom kombinacijom ciprofloksacina i ceftriaksona. Nakon neuspjele empirijske antimikrobne terapije uzeta je detaljna nadopuna epidemiološke anamneze iz koje smo saznali da je bolesnik 15 dana prije početka bolesti radio na gradilištu autoceste Rijeka–Zagreb. U to vrijeme često je vadeći kamenje boravio u vodi gdje je bilo glodavaca i uginulih životinja. Na osnovi ovih epidemioloških podataka i inicijalnog terapijskog neuspjeha, diferencijalno-dijagnostički smo u obzir uzeli i tularemiju koja je potvrđena naknadno učinjenim serološkim testovima. Prikazom ovog bolesnika željeli smo ponovo ukazati na važnost uzimanja epidemiološke anamneze i češćeg pomišljanja na tifoidni oblik tularemije u obradi bolesnika s dugotrajnim febrilitetom bez vodećeg simptoma.Tularemia is an acute, febrile, granulomatous zoonosis, primarily a disease of rodents. It is transmitted to humans by direct contact with sick animals, animal or insect bite, ingestion of infected meat, water, or inhalation of aerosols from infected animals or dust. The mode of transmission determines the development of clinical manifestations of this zoonosis. A 43-year-old patient from Zagreb was admitted to the University Hospital for Infectious Diseases "Dr Fran Mihaljevic" in Zagreb on the ninth day of illness manifested with remittent fever without leading symptoms. Due to fever of unknown cause the patient was treated with symptomatic as well as empirical therapy at first with parenteral co-amoxiclav, and then with a combination of ciprofloxacin and ceftriaxone. After unsuccessful empirical antimicrobial therapy, a detailed update of epidemiological history was taken from which we learned that 15 days before disease onset the patient had been working at a construction site of Rijeka-Zagreb motorway where he extracted stones from water polluted with rodents and dead animals. Based on these epidemiological data and initial treatment failure, tularemia has been taken into account in differential diagnosis, which was subsequently confirmed by serological testing. With this case report, we wanted to re-emphasize the importance of taking detailed epidemiological history and considering typhoid form of tularemia in patients with prolonged fever without leading symptoms

Imaging Techniques and Multidiciplinary Approach to the Vertebral Osteomyelitis

Dijagnoza osteomijelitisa kralješnice jest teška i često zakašnjela ili čak propuštena. Napredak u radiološkim metodama oslikavanja (kompjutoriziranoj tomografiji-CT i magnetskoj rezonanciji-MR), poboljšao je prognozu u bolesnika s ovom bolešću. CT predstavlja najbolju metodu za detekciju koštanih promjena, osobito za destrukciju pokrovnih ploha kralješaka u ranoj fazi upale. MR je superiornija slikovna metoda u ovoj indikaciji jer kombinira visoku osjetljivost sa zadovoljavajućom specifičnošću. Predstavlja metodu izbora u prikazu izravnog širenja infekcije, osobito epiduralnog apscesa i flegmone te posljedične neuralne kompresije. MR-om je također moguće i bolje praćenje terapijske učinkovitosti.The diagnosis of vertebral spondylodiscitis is difficult and often delayed or missed. The development of radiological techniques (Computerized Tomography-CT and Magnetic Resonance Imaging-MRI) have improved the outcome for patients with this condition. CT is the best method for the detection of bone changes, especially vertebral end-plate destruction. The MRI is the preferred imaging method because it combines high sensitivity with satisfactory specificity. It is the method of choice for direct demonstration of extension of infection, especially epidural abscess or phlegmon and consecutive neural compression. In addition, MRI enables good monitoring of therapeutic efficiency

Evaluation of periodontal status in HIV infected persons in Croatia [Procjena parodontološkog statusa oboljelih od HIV-a u Republici Hrvatskoj]

A number of periodontal changes have been associated with human immunodeficiency virus (HIV) infection, however our knowledge of the epidemiology, microbiology, host response and natural history of these conditions remains limited. Therefore, the aim of our study was the assessment of possible differences in periodontal status of HIV infected subjects when compared with healthy controls matched for age, gender and smoking habit in Croatian population. Assessment included measurement of plaque accumulation using approximal plaque index, measurement of gingival inflammation by use of sulcus bleeding index, pocket depth, gingival recession as well as the number of decayed, missing and filled teeth in 25 HIV infected subjects (age range 22-61, X = 40.8 years) in comparison with 25 healthy controls (age range 20-62, X = 40.9 years). Statistical analysis was performed by use of descriptive statistics and Mann-Whitney U test showed significantly increased level of inflammation of the marginal gingiva in HIV infected subjects when compared to the controls (p < 0.002). Significantly increased mean values of periodontal pockets (p < 0.002) and the deepest periodontal pocket (p < 0.003) were also observed when HIV infected subjects were compared to the healthy controls. In HIV infected subjects there was significant increase in the number of decayed, missing and decrease in the number of filled teeth (p < 0.002; p < 0.002; p < 0.009, respectively). The results of this study once again highlight the need for more prevalent periodontal check-ups and treatments in HIV infected subjects

Acase report of brucellosis and sacroiliitis with clinical and epidemiological overview

Bruceloza je zoonoza rasprostranjena u nekih domaćih i divljih životinja koja se u rijetkim slučajevima može prenijeti i na ljude. Bolesnik iz Bosne i Hercegovine zaprimljen je u našu Kliniku zbog razjašnjenja etiologije rekurirajućeg intermitentnog febriliteta u trajanju od skoro dva mjeseca praćenog bolovima u križima i donjim ekstremitetima zbog čega je postao nepokretan. Bolesnik je najprije hospitaliziran u kirurškoj klinici gdje su mu učinjeni radiogram kralježnice s kukovima, višeslojna kompjutorizirana tomografija i MR kralježnice na kojima je nađena protruzija diska L5/S1, ali ne i osnovni uzrok bolesti. Stoga je premješten u Kliniku radi dalje obrade i liječenja. Nadopunom anamneze doznali smo da bolesnik živi na seoskom domaćinstvu gdje se bavi uzgojem ovaca zbog čega se postavila sumnja na brucelozu. Dijagnoza bruceloze postavljena je serološkim metodama, PCR-om i izolacijom Brucella mellitensis iz krvi bolesnika, a scintigrafija skeleta pokazala je patološko nakupljanje radiofarmaka u sakroilijakalnim zglobovima. Provedeno je kombinirano antimikrobno liječenje kroz osam tjedana: kombinacijom doksiciklina i rifampicina šest tjedana, a potom još dva tjedna doksiciklinom i ciprofloksacinom. Bolesnik je iz Klinike otpušten u dobrom općem stanju, afebrilan, pokretan i bez simptoma bolesti. Ovim prikazom htjeli smo istaknuti važnost uzimanja epidemiološke anamneze kao i pomišljanja na brucelozu u bolesnika koji dolaze iz susjednih zemalja u kojima je bruceloza česta. Veterinarske mjere kontrole i nadzora bruceloze u životinja kao i nadzor nad stokom koja se importira iz susjednih zemalja najvažnije su preventivne mjere u sprječavanju ove bolesti i u ljudi.Brucellosis is a zoonotic infectious disease found in some domestic and wild animals that in rare cases may be transmitted to humans as well. A patient from Bosnia and Herzegovina was admitted to our hospital for unclear etiology of recurrent intermittend fever lasting for almost two months accompanied by pain in the back and lower extremities causing his inability to move. The patient was at first hospitalized in a surgical clinic where spine and hip radiogram was performed as well as multislice computer tomography and magnetic resonance imaging of the spine that showed disc protrusion at L5/S1, but not the underlying cause of disease. Therefore, he was transferred to our hospital for further examination and treatment. Additional patient history revealed that the patient lived on a homestead where he raised sheep which is why brucellosis was suspected. Brucellosis diagnosis was confirmed by serological testing, PCR and isolation of Brucella mellitensis from the patient’s bood sample, and skeletal scintigraphy showed a pathological accumulation of radioactive agents in the sacroiliac joints. Acombined antimicrobial therapy lasting for eight weeks was administered: a combination of doxycycline and rifampicin for six weeks, then additional two weeks of doxycycline and ciprofloxacin. The patient was discharged from hospital in good general condition, without fever, able to move and without disease symptoms. This case report underlines the importance of collecting epidemiological data as well as considering brucellosis in patients coming from neighbouring countries where brucellosis is common. Veterinary measures for brucellosis control and surveillance in animals as well as surveillance of cattle imported from neighbouring countries are most important preventive measures for disease transmission among humans