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Hu M, Liu M, Jin S, Wang X, Liu X. Clinical features, treatment and prognosis of patients with endogenous infectious endophthalmitis. Int Ophthalmol 2024; 44:321. [PMID: 38977562 DOI: 10.1007/s10792-024-03208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/15/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE To investigate whether the clinical characteristics, treatment and prognosis of endogenous infectious endophthalmitis (EIE) have changed over the past 5 years. METHODS Retrospectively analyze all articles about EIE published in the PubMed, Web of Science, and Embase databases from 2017 to 2021. RESULTS A total of 128 patients and 147 eyes (46 left and 60 right) were included in the study. The mean age at diagnosis was 51 ± 19 years. The most common risk factors were diabetes and intravenous drug use. From 2017 to 2021, Klebsiella was the most common pathogenic microorganism (22%), and vitreous culture had the highest positivity rate. The most common complaint was blurred vision. The mean visual acuity (logMAR) at onset was 2.84, and the clinical symptoms were vitreal inflammation and opacity (63%), ocular pain (37%), and conjunctival congestion (36%). The ocular inflammation could be reduced by intraocular antibiotics or vitrectomy. However, the visual prognosis, with a mean logMAR of 2.73; only 50% of the eyes reached a visual acuity level of finger count and above. Changes in diagnostics over the past 5 years have mainly manifested as more diverse microorganism culture methods. In addition to conventional culture methods, PCR, sputum culture and aqueous humour culture are also commonly used for the diagnosis of pathogenic bacteria, improving the positive culture rate and visual prognosis. CONCLUSION The prognosis of EIE is poor. It is recommended to pay attention to the pathogenic bacteria culture results and accompanying systemic diseases and to diagnose and treat patients as soon as possible.
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Affiliation(s)
- Mingjing Hu
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Mingzhu Liu
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Siyan Jin
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Xia Wang
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China
| | - Xiaoli Liu
- Ophthalmologic Center of the Second Hospital, Jilin University, Ziqiang Street 218, Changchun, 130000, People's Republic of China.
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Tada K, Shibata R, Nakamura T, Kawaguchi Y, Nakano Y, Ishii H, Ura K, Yamada H, Maekawa S, Ito K, Masutani K. Severe disseminated infection by hypermucoviscous Klebsiella pneumoniae successfully treated by intensive therapy with continuous hemodiafiltration using AN69ST: A case report and review of the literature. J Infect Chemother 2023; 29:1075-1080. [PMID: 37451619 DOI: 10.1016/j.jiac.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/09/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
Klebsiella pneumoniae (Kpn) is one of the most common gram-negative bacilli causing lung, urinary tract, and biliary tract infections. However, as a distinct entity from classic Kpn, hypervirulent Kpn causing liver abscess, endophthalmitis, and lung abscess with poor prognoses has been reported mainly in East and Southeast Asia since the mid-1980s. Although the definition of hypervirulent Kpn is unclear, the hypermucoviscosity of Kpn is considered an important feature of hypervirulence. We present a case of emphysematous pyelonephritis accompanied by septic shock and acute kidney injury caused by hypermucoviscous Kpn infection that was successfully treated by intensive treatment. A 70-year-old woman with type 2 diabetes mellitus was diagnosed with emphysematous pyelonephritis, and string test-positive Kpn was detected in blood and urine cultures and percutaneous catheter drainage fluid from the renal pelvis. The patient was treated with intensive therapies including antibiotics, ventilator management, and continuous hemodiafiltration (CHDF) using AN69ST, which can absorb cytokines. During the course of treatment, the infection was complicated by pyogenic spondylitis, which was cured by antimicrobial therapy, and the patient was transferred to another hospital for rehabilitation on day 119 after admission. Hypermucoviscous Kpn infection often has a severe course, and it is important to initiate multidisciplinary treatment at an early stage, including rifampicin, which is expected to inhibit the viscosity of hypermucoviscous Kpn. In the current case, immediate CHDF using AN69ST was also considered a life-saving treatment because it improved both volume overload and neutrophil-activated hypercytokinemia.
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Affiliation(s)
- Kazuhiro Tada
- Department of Nephrology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan.
| | - Ryoko Shibata
- Department of Nephrology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Tsubasa Nakamura
- Department of Nephrology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | | | - Yuki Nakano
- Department of Pharmacy, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Hidehiro Ishii
- Department of Diabetology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Kazuya Ura
- Department of General Internal Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Hiroyoshi Yamada
- Department of Respiratory Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Shinichi Maekawa
- Department of General Thoracic Surgery, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Kenji Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Neerhut T, Ninan J, Crozier J, Lawson M, Rhee H. Urgent nephrectomy for rapidly progressive disseminated metastatic Hypermucoid Klebsiella. Urol Case Rep 2022; 44:102157. [PMID: 35846515 PMCID: PMC9283878 DOI: 10.1016/j.eucr.2022.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/02/2022] Open
Abstract
Few cases of Hypervirulent Klebsiella Pneumonia (HvKP) have been described. Even fewer cases with renal abscess and metastatic pulmonary spread are reported. Typically, prompt introduction of intravenous antibiotics leads to clinical resolution and more invasive measures of source control are rarely required. To date only one other case of disseminated metastatic HvKP requiring nephrectomy for infective source control is described. Here we present a rare case of metastatic HvKP refractory to intravenous antimicrobial therapy in an immunocompromised newly diagnosed diabetic patient. Specifically, we seek to illustrate the rapid effectiveness of surgical intervention following a poor response to initial treatment.
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Affiliation(s)
- Thomas Neerhut
- Princess Alexandra Hospital, Brisbane, 199 Ipswich Road, Woolloongabba, 4102, Australia
- Corresponding author. 199 Ipswich Road, Woolloongabba, 4102, Australia.
| | - John Ninan
- Princess Alexandra Hospital, Brisbane, 199 Ipswich Road, Woolloongabba, 4102, Australia
| | - Jack Crozier
- Princess Alexandra Hospital, Brisbane, Australia
| | | | - Handoo Rhee
- Princess Alexandra Hospital, Brisbane, Australia
- University of Queensland, Australia
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Peng W, Wu Y, Lu R, Zheng Y, Chen J, Pan P. Successful treatment of acute respiratory distress syndrome caused by hypervirulent Klebsiella pneumoniae with extracorporeal membrane oxygenation and continuous renal replacement therapy: A case report and literature review. Front Med (Lausanne) 2022; 9:936927. [PMID: 36091705 PMCID: PMC9449315 DOI: 10.3389/fmed.2022.936927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
Hypervirulent Klebsiella pneumoniae (hvKP) causes invasive infections and leads to high morbidity and mortality rates. Here, we report the case of a Chinese man with diabetes mellitus who developed acute respiratory distress syndrome and septic shock due to hvKP belonging to the K1 strain. The patient was treated with venovenous extracorporeal membrane oxygenation and continuous renal replacement therapy, in combination with antibiotics and recovered well. Clinicians should be aware of fatal infections caused by hvKP and investigate the best treatment options for patients at various stages of infection.
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Affiliation(s)
- Wenzhong Peng
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yanhao Wu
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Rongli Lu
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yunpeng Zheng
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Chen
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Pinhua Pan
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Pinhua Pan
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Chen KJ, Chen YP, Chen YH, Liu L, Wang NK, Chao AN, Wu WC, Hwang YS, Chou HD, Kang EYC, Chen YT, Sun MH, Lai CC. Infection Sources and Klebsiella pneumoniae Antibiotic Susceptibilities in Endogenous Klebsiella Endophthalmitis. Antibiotics (Basel) 2022; 11:866. [PMID: 35884120 PMCID: PMC9311537 DOI: 10.3390/antibiotics11070866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/19/2022] [Accepted: 06/25/2022] [Indexed: 12/10/2022] Open
Abstract
Endogenous endophthalmitis is an uncommon intraocular infection with potentially devastating consequences on vision. Klebsiella pneumoniae is highly prevalent in East Asian countries, with an increasing incidence recently worldwide. This retrospective study investigates infection sources and antibiotic susceptibilities of K. pneumoniae in patients with endogenous K. pneumoniae endophthalmitis (EKE) in Northern Taiwan. One hundred and fifty-seven patients with EKE were reviewed between January 1996 and April 2019. Pyogenic liver abscess (120/157, 76.4%) was the most common infection source, followed by pneumonia (13, 8.3%), urinary tract infection (7, 4.5%), and intravenous drug use (4, 2.5%). Bilateral involvement was identified in 12.1% (19/157) of patients, especially in patients with pyogenic liver abscess (16/120, 13.3%), pneumonia (2/13, 15.4%), and urinary tract infection (1/7, 14.3%). The antibiotic susceptibility rates were 98.1%, 92.5%, 97.5%, 96.8%, 100%, 99.3%, and 100% for amikacin, cefuroxime, ceftazidime, ceftriaxone, carbapenems, ciprofloxacin, and levofloxacin, respectively. Four extended-spectrum β-lactamase-producing multidrug-resistant (MDR) K. pneumoniae isolates were identified. In conclusion, pyogenic liver abscess was the major infection source in EKE. In addition, K. pneumoniae was still highly susceptible to ceftazidime and amikacin, and the MDR K. pneumoniae isolates were not common in EKE.
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Affiliation(s)
- Kuan-Jen Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yen-Po Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, Tucheng Municipal Hospital, Tucheng, New Taipei 236, Taiwan
| | - Yi-Hsing Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Laura Liu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Nan-Kai Wang
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University, New York, NY 10032, USA;
| | - An-Ning Chao
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Hung-Da Chou
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Eugene Yu-Chuan Kang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yen-Ting Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
| | - Ming-Hui Sun
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (Y.-P.C.); (Y.-H.C.); (L.L.); (A.-N.C.); (W.-C.W.); (Y.-S.H.); (H.-D.C.); (E.Y.-C.K.); (Y.-T.C.); (M.-H.S.); (C.-C.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung 204, Taiwan
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Serban D, Popa Cherecheanu A, Dascalu AM, Socea B, Vancea G, Stana D, Smarandache GC, Sabau AD, Costea DO. Hypervirulent Klebsiella pneumoniae Endogenous Endophthalmitis-A Global Emerging Disease. Life (Basel) 2021; 11:life11070676. [PMID: 34357049 PMCID: PMC8304989 DOI: 10.3390/life11070676] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 11/16/2022] Open
Abstract
The review aims to document the new emerging hypervirulent Klebsiella pneumoniae (Kp) endogenous endophthalmitis (EKE) in terms of incidence, microbiological characterization of the pathogenic agent, associated risk factors, management, and outcomes. Hypervirulent (hv) strains of KP (hvKp) induce invasive liver abscesses (LA) with specific clinical features. Up to 80–90% of cases have hepatic liver abscess as a primary focus of infection, followed by renal or lung hvKp infections. However, the incidence of EKE in patients with KPLA varied between 3.4% (19) and 12.6% (13), with a total of 95 cases of endophthalmitis in 1455 cases of KPLA (6.5%). Severe visual loss was encountered in 75% of cases, with 25% bilateral involvement. Intravitreal antibiotics are the mainstay therapeutic approach. Pars plana vitrectomy is a subject of controversy. HvKp strains present mostly natural “wild-type” antibiotic resistance profile suggestive for community-acquired infections, being highly susceptive to the third and fourth generation of cephalosporins and carbapenems. Antimicrobial resistance in hypervirulent strains was recently documented via plasmid transfer and may result in extremely difficult to treat cases. Global dissemination of these strains is a major epidemiologic shift that should be considered in the diagnostic and therapeutic management of patients with endogenous endophthalmitis. Ophthalmologic screening in patients with KPLA and other hvKp infections and a multidisciplinary therapeutic approach is extremely important for early diagnosis and preservation of the visual function.
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Affiliation(s)
- Dragos Serban
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- 4th Department of General Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Alina Popa Cherecheanu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- Department of Ophthalmology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania;
| | - Ana Maria Dascalu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- Department of Ophthalmology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania;
- Correspondence: (A.M.D.); (B.S.)
| | - Bogdan Socea
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- Department of Surgery, “Sf Pantelimon” Emergency Hospital Bucharest, 021659 Bucharest, Romania
- Correspondence: (A.M.D.); (B.S.)
| | - Geta Vancea
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- “Victor Babes” Infectious and Tropical Disease Hospital Bucharest, 030303 Bucharest, Romania
| | - Daniela Stana
- Department of Ophthalmology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania;
| | - Gabriel Catalin Smarandache
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020011 Bucharest, Romania; (D.S.); (A.P.C.); (G.V.); (G.C.S.)
- 4th Department of General Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Alexandru Dan Sabau
- 3rd Clinical Department, Faculty of Medicine, “Lucian Blaga” University Sibiu, 550024 Sibiu, Romania; (A.D.S.); (D.O.C.)
| | - Daniel Ovidiu Costea
- 3rd Clinical Department, Faculty of Medicine, “Lucian Blaga” University Sibiu, 550024 Sibiu, Romania; (A.D.S.); (D.O.C.)
- Faculty of Medicine, Ovidius University Constanta, 900527 Constanta, Romania
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