Seroconversion after SARS-CoV-2 vaccination is protective against severe COVID-19 disease in heart transplant recipients

BACKGROUND

Heart transplant (HTX) recipients are prone to develop complications after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Vaccination is often ineffective due to weaker immunogenicity. In this high-volume single-center study, we aimed to determine factors influencing seroconversion after vaccination and predictors of severe SARS-CoV-2 infection.

METHODS

Two hundred twenty-nine HTX recipients were enrolled. Type of the first two vaccine doses included messenger RNA (mRNA), vector, and inactivated vaccines. We carried out analyses on seroconversion after the second and third doses of vaccination and on severity of infection. Antispike protein SARS-CoV-2 immunoglobulin G (IgG) was measured after the second and third vaccines and serostatus was defined. Effect of the first two vaccine doses was studied on patients who did not suffer SARS-CoV-2 infection before antibody measurement (n = 175). The effectivity of the third vaccine was evaluated among seronegative recipients after the second vaccine (n = 53). Predictors for severe infection defined as pneumonia, hospitalization or death were assessed in all patients who contracted SARS-CoV-2 infection (n = 92).

RESULTS

62% of the recipients became seropositive after the second vaccination. Longer time between HTX and vaccination (odds ratio [OR]: 2.35) and mRNA vaccine (OR: 4.83) were predictors of seroconversion. 58% of the nonresponsive patients became seropositive after receiving the third vaccine. Male sex increased the chance of IgG production after the third dose (OR: 5.65). Clinical course of SARS-CoV-2 infection was severe in 32%. Of all parameters assessed, only seropositivity before infection was proven to have a protective effect against severe infection (OR: 0.11).

CONCLUSIONS

We found that longer time since HTX, mRNA vaccine type, and male sex promoted seroconversion after SARS-CoV-2 vaccination in HTX recipients. Seropositivity-but not the number of vaccine doses-seemed to be protective against severe SARS-CoV-2 infection. Screening of HTX patients for anti-SARS-COV-2 antibodies may help to identify patients at risk for severe infection.

Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection

BACKGROUND

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR).

METHODS

We reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%).

CONCLUSIONS

Based on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.

Rifampicin resistance and risk factors associated with significantly lower recovery rates after two stage revision in patients with prosthetic joint infection

PURPOSE

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favorable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing two-stage revision.

METHODS

We reviewed medical records and microbiology reports of 73 patients (41 males and 32 females) undergoing two-stage revision due to PJI between 2017 and 2019. Patient-specific data, co-morbidities and the antibiotic resistance of microbiological isolates were registered. 48 patients had hip, 22 had knee, 2 had shoulder and 1 had elbow joint infection. Obtained data were statistically analyzed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 53 cases (72.6%). Recovery rate was 92.5% in the sensitive and 60.0% in the resistant group. We observed that rifampicin resistance significantly reduced the probability of recovery. Furthermore, in the rifampicin-sensitive group, the probability of recovery decreased with advancing age with a significant drop above the age of 60 years. The effect of age is negligible in the rifampicin-resistant group. We also found that type 2 diabetes mellitus has a negative effect on recovery. Coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (50% of the isolates) and Gram-negative rods in the resistant group (40%).

CONCLUSIONS

Rifampicin resistance was associated with lower recovery rates among patients undergoing two-stage revision due to PJI. Higher age and type 2 diabetes mellitus had negative impact on clinical outcome.

Pseudoaneurysm of the ascending aorta: case report of a donor-derived Pseudomonas infection in a heart transplant recipient

Background

Mycotic aortic pseudoaneurysm is a rare complication after heart transplantation (HTX) with remarkable mortality. Intrathoracic infection is a well-documented predisposing factor for this disease. Staphylococcus aureus, Pseudomonas aeruginosa or Candida species are commonly isolated from resected specimens of the pseudoaneurysms. We demonstrate a unique case of mycotic pseudoaneurysm caused by presumably donor-derived Pseudomonas infection in a heart transplant recipient.

Case presentation

Our 67-year-old male patient treated with diabetes mellitus underwent HTX. The donor suffered from epiglottic abscess and pneumonia with known microorganisms including Pseudomonas, therefore both the donor and recipient received targeted antimicrobial therapy and prophylaxis. Five months after the uneventful HTX, lab test of the asymptomatic patient showed moderate, increasing C-reactive protein level without obviuos source of infection. Chest computed tomography showed a large (90 mm) saccular dilatation of the tubular portion of ascending aorta. Urgent surgical intervention identified a pseudoaneurysm, histological examinations and cultures of the resected aorta verified Pseudomonas aeruginosa aortitis, while all blood cultures remained negative. Retrospective interrogation of other transplanted organs of the donor supported donor-derived infection as the transport fluid of the right kidney grew Pseudomonas. The patient received 3 weeks of ceftazidime followed by 7 months of oral ciprofloxacin therapy. One year after the operation the patient was asymptomatic with normal inflammatory markers.

Conclusions

Donor-derived infection is a rare but potential cause of aortitis. Early diagnosis, surgical intervention and adjuvant antibiotic therapy seem to be the keys to successful management of mycotic pseudoaneurysms after HTX.

Novel coronavirus epidemic in the Hungarian population, a cross-sectional nationwide survey to support the exit policy in Hungary

After months of restrictive containment efforts to fight the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) epidemic, European countries are planning to reopen. To support the process, we conducted a cross-sectional survey among the Hungarian population to estimate the prevalence of infectious cases and prior SARS-CoV-2 exposure. A representative sample (n = 17,787) for the Hungarian population of 14 years or older living in private households (n = 8,283,810) was selected. The study was performed within 16 days after 50 days of restrictions, when the number of confirmed cases was stable low. Naso- and oropharyngeal smears and blood samples were collected for PCR and antibody testing. The testing was accompanied by a questionnaire about symptoms, comorbidities, and contacts. Design-based prevalence estimates were calculated. In total, 10,474 individuals (67.7% taken into account a sample frame error of 2315) of the selected sample participated in the survey. Of the tested individuals, 3 had positive PCR and 69 had positive serological test. Population estimate of the number of SARS-CoV-2 infection and seropositivity were 2421 and 56,439, respectively, thus active infection rate (2.9/10,000) and the prevalence of prior SARS-CoV-2 exposure (68/10,000) was low. Self-reported loss of smell or taste and body aches were significantly more frequent among those with SARS-CoV-2. In this representative, cross-sectional survey of the Hungarian population with a high participation rate, the overall active infection rate was low in sync with the prevalence of prior SARS-CoV-2 exposure. We demonstrated a potential success of containment efforts, supporting an exit strategy. NCT04370067, 30.04.2020.

P346 The changing epidemiology of infective endocarditis in a tertiary center

Background

Despite the adequate antibiotic prophylaxis, the incidence and mortality rate of infective endocarditis (IE) is still high. In the past few decades, several studies have noted an increase in the proportion of IE caused by staphylococcal species.

Aims

The aim of our retrospective study was to assess the clinical and microbiological characteristics, trends, and the 1, 6 and 12-month cardiovascular (CV) mortality rate of patients administered for IE in our tertiary hospital between January 1, 2006 and December 31, 2016.

Results

We identified 465 cases (311 men, 154 women) of 448 patients, mean age was 56,1 ± 16,4 years (14-92). Native left-sided IE (NLIE) was assessed in 286 cases (61,5%, mitral in 117, aorta in 116, combined in 53 cases), prosthetic valve IE (PVIE) was in 111 cases (24%, early in 44, late in 67), right-sided IE (RIE) in 12 cases (2,5%), cardiac device related IE (CDRIE) in 50 cases (11%), other in 6 cases (1%). The underlying infection was caused by streptococci in 124 cases (27%), Staphylococcus aureus (SA) in 112 cases (24%, out of them 23 had MRSA), coagulase negative Staphylococcus (CoNS) in 39 cases (8%), enterococci in 75 cases (16%). Blood culture negative cases found in 61 patients (13%), in 38 cases (8%) other, diversified germs and in 16 cases (4%) there were no data on the pathogen agent.

The mortality rates of the total population were

one-month was 12.8%, six-month was 26.4%, one-year was 29.7%, and five-year was 40%. There was a significant difference in the mortality rate regarding both of the type of IE and in terms of the underlying microorganism (log-rank p = 0.03 and p = 0.04 resp). The worst survival rate was detected among patients with PVIE, and patients with staphylococcal infection, especially with MRSA. Cox regression found that age (HR: 1.4; CI:1.3-1.6; p <0.001), ejection fraction (HR: 1.4; CI:1.2-1.5; p <0.001), hemoglobin and creatinin levels (HR: 0.9; CI:0.8-0.97 p = 0.01; HR: 1.3; CI: 1.1-1.5; p = 0.001 resp.), MRSA compared to streptococcal infection (HR: 2.5; CI:1.4-4.5; p <0.001), stroke as complication (HR: 1.98; CI:1.4-2.8; p <0.001) were independent risk factors of mortality.

In terms of temporal trends the rate of combined NLIE decreased over time (14.5% to 5.1%, p = 0.03), while the rate of other types of IE did not changed. Regarding the type of underlying microorganism the rate of SA infection increased (17% to 41%, p = 0.002) and the rate of CoNS decreased (16.1% - 1.3% p < 0.001) over time. The 1-year mortality rate did not change through the years.

Conclusions

During the observed 11 years 465 cases were administered with IE to our tertiary hospital, out of which two-third were NLIE. One-quarter of the underlying microorganism were streptococci, and the rate of Staphylococcus aureus infection was increased over time, which was associated with a worse prognosis. In addition IE had a high mortality, which unfortunately did not improve through the years.

472 Epidemiology and temporal trends of cardiac device related infective endocarditis

Background

Infective endocarditis (IE) is a rare, but life-threatening complication of cardiac device implantation. Despite recent preventive strategies, and advances in antimicrobial and surgical treatment, morbidity and mortality rates are still high.

Aims

The objective of our study was to assess the epidemiological characteristics, temporal tends and mortality rate of cardiac device related IE (CDRIE) in our high-volume, tertiary referral center.

Methods

retrospective data collection was performed from January 1, 2006 to December 31, 2016. Thirty-day, 6-month and 1-year mortality was estimated, which were compared to left-sided native valve endocarditis (LSNIE). Patients administered between 2006 and 2010 and between 2011 and 2016 were compared to assess temporal trends.

Results

465 cases of IE were administered, out of whom 54 patients had CDRIE (39 males [72%], mean age: 55.8 ±19 yrs; 4 VVI, 7 VDD, 7 VVI-ICD, 20 DDD, 5 DDD-ICD and 11 CRT devices; median time since first implantation: 1558 days [IQR: 470 days – 8.6 yrs]). The infection was caused by streptococci in 3 cases (5.5%), Staphylococci were the most prevalent infective agents (70%), S. aureus (SA) in 28 cases (52%, out of whom 10 were MRSA), coagulase negative Staphylococcus in 10 cases (18.5%), blood culture negative cases in 8 patients (15%), and in 5 cases other pathogens were responsible. 266 patients had LSNIE (201 males [75%], mean age: 54.4 ± 15.6 yrs). There was no difference between the two groups in age or in portion of males. Mortality rates were the same in CDRIE group compared to LSNIE group (30-day: 13% vs 13%, 6-month: 20% vs 25%, 1-year: 26% vs 29% and long-term: 44% vs 44%, ns resp.) Patients who died in the CDRIE group (n = 25) were older (64 yrs [IQR:59-71 yrs] vs 52 yrs [IQR: 27-69 yrs], p = 0.02), male sex was less common (52% vs 79%, p = 0.03), had lower ejection fraction (39.6 ±16.6% vs 54.6 ±14.5%, p < 0.001), had worse renal function (GFR: 46.3 ± 15.3 vs 60.2 ± 23.5 ml/min/1.73m2, p = 0.04), shorter time since first device implantation (2.1 yrs [IQR: 1.1-4.8 yrs] vs 6.7 yrs [4.1-12.9 yrs], p = 0.006), and CRT device implantation were more prevalent (32% vs 10%, p < 0.05).

Patients admitted before 2011 (n = 22) did not differ from patients admitted after 2011 (n = 32) in terms of age, male gender, concomitant valve infection, pocket infection, or embolic event. The 30-day (0% vs 6%) and the 1-year mortality (18% vs 31%) were the same before and after 2011, but the 6-month mortality was better before 2011 (4.5% vs 31%, p = 0.01). CRT device implantation was more prevalent over time (5% vs 31%, p = 0.01), and SA infection became more frequent (36% vs 63%, p = 0.05)

Conclusions

During the last decade patients with CDRIE had a same survival as patients with LSNIE, every fourth patient died one year after the diagnosis. Almost three-quarter of the infections were caused by Staphylococci, and the portion of S. aureus infection increased over time.

[Periprosthetic joint infection caused by Rhodococcus equi. Case report]

Rhodococcus equi is a rare pathogen in humans causing infections mostly in immunocompromised hosts. We present the first case of periprosthetic joint infection caused by Rhodococcus equi. An 88-year-old male patient was referred to our clinic with a history of fever and right hip pain. The patient had multiple hip surgeries including total joint arthroplasty and revision for aseptic loosening on the right side. He was immunocompetent, but his additional medical history was remarkable for diabetes mellitus, diabetic nephropathy and stroke with hemiplegia resulting in immobilization. Radiography showed stable components, joint aspirate yielded Rhodococcus equi. Irrigation and debridement was proposed, but the patient refused any surgical intervention. Therefore antibiotic therapy was administered. At the last follow-up the patient is free of complaints but the C-reactive protein level is still elevated. This case illustrates the possible role of Rhodococcus equi in medical device-associated infections. Orv Hetil. 2017; 158(27): 1071-1074.

MicroRNA-146a reduces MHC-II expression via targeting JAK/STAT signaling in dendritic cells after stem cell transplantation

Acute Graft-versus-host disease (GVHD) is a major immunological complication after allogeneic hematopoietic cell transplantation and a better understanding of the molecular regulation of the disease could help to develop novel targeted therapies. Here we found that a G/C polymorphism within the human microRNA-146a (miR-146a) gene of transplant-recipients, which causes reduced miR-146a levels, was strongly associated with the risk of developing severe acute GVHD (n=289). In mice, deficiency of miR-146a in the hematopoietic system or transfer of recipient-type miR 146a^-/- dendritic cells (DCs) enhanced GVHD, while miR-146a mimic-transfected-DCs ameliorated disease. Mechanistically, lack of miR-146a enhanced JAK2 STAT1-pathway activity, which led to higher expression of class II-transactivator (CIITA) and consecutively increased MHCII-levels on DCs. Inhibition of JAK1/2 or CIITA knockdown in DCs prevented miR-146a^-/- DC-induced GVHD exacerbation. Consistent with our findings in mice, patients with the miR-146a polymorphism rs2910164 in hematopoietic cells displayed higher MHCII levels on monocytes, which could be targeted by JAK1/2-inhibition.

Our findings indicate that the miR-146a polymorphism rs2910164 identifies patients at high risk for GVHD before allo HCT. Functionally we show that miR-146a acts as a central regulator of recipient-type DC activation during GVHD by dampening the pro-inflammatory JAK-STAT/CIITA/MHCII axis, which provides a scientific rationale for early JAK1/2-inhibition in selected patients.

Diagnostic problems of the mucormycosis of the maxillary sinus Case presentation

Mucormycosis is a fulminant opportunistic infection with significant mortality in susceptible individuals. Although mortality rates vary widely (30 to 100%) according to professional literature, recently in instances with no central nervous system (CNS) involvement the survival rate averages varies between 50 and 80% owing to complex therapy. With CNS involvement, however, the fatality rate is over 80%. Predisposing diseases include diabetes mellitus, malnutrition, hematologi- cal diseases, neutropenia, burns, surgical procedures, antibiotic treatments, long-term steroid therapy and immunosuppressive therapy. Mucormycosis may at times arise even in -immunocompetent individuals. It has diverse clinical forms with the most frequent forms being rhino-maxillary and rhino-oculocerebral (the latter of which is characterized by a high mortality rate). They mainly enter the body through inhalation, with saprophytic mucor species often demonstrable in the upper respiratory tracts, which are nevertheless non-pathogenic in most healthy individuals. The spores may also enter percutaneously through traumas, skin lesions, insect bites, or injections (e.g. through intravenous drug use); as well as via the alimentary tract with contaminated foodstuff. The prognosis can be improved by a quick establishment of the diagnosis, the quick initiation of the therapy and treatment of the underlying disease. Although first and foremost the recognition and treatment of the disease does not rest with dentists and oral surgeons, in order to localize the disease it is important to examine it from a differential diagnostic point of view and interdisciplinary cooperation may also be required in a complex treatment. Our aim is to introduce mucormycosis in our case report study.

[Thousand faces of Streptococcus pneumonia (pneumococcus) infections]

Incidence and mortality rates of infections caused by Streptococcus pneumoniae (pneumococcus) are high worldwide and in Hungary among paediatric as well as adult populations. Pneumococci account for 35-40% of community acquired adult pneumonias requiring hospitalization, while 25-30% of Streptococcus pneumoniae pneumonias are accompanied by bacteraemia. 5-7% of all infections are fatal but this rate is exponentially higher in high risk patients and elderly people. Mortality could reach 20% among patients with severe invasive pneumococcal infections. Complications may develop despite administration of adequate antibiotics. The authors summarize the epidemiology of pneumococcal infections, pathogenesis of non-invasive and invasive disease and present basic clinical aspects through demonstration of four cases. Early risk stratification, sampling of hemocultures, administration of antibiotics and wider application of active immunization could reduce the mortality of invasive disease. Anti-pneumococcal vaccination is advisable for adults of ≥50 years and high risk patients of ≥18 years who are susceptible to pneumococcal disease.

[The role of virological tests in the diagnosis of cytomegalovirus infection in pregnant women]

INTRODUCTION

The most harmful and most frequent foetal agent is cytomegalovirus. The progress in diagnostic tools and therapeutic opportunities opened new perspectives in the diagnosis and management of foetal cytomegalovirus infection.

AIM

Evaluation of cytomegalovirus virological test results performed during pregnancy between 2007 and 2012.

METHOD

Clinical and virology data were retrospectively analysed.

RESULTS

64.5% of the 956 tested women were serologically protected and 33.3% were susceptible to cytomegalovirus. Recent infection was confirmed in 10 pregnant women, while the infection could not be confirmed or excluded in 3 pregnant women. Six pregnant women were asymptomatic, 5 had typical disease, and 2 had abnormal fetal ultrasound. One fetus aborted, congenital infection was confirmed in 2, and was excluded in one of the four newborns tested.

CONCLUSIONS

The immunity of women to cytomegalovirus reflects high socioeconomic circumstances. Confimatory tests must be done both in women who have cytomegalovirus disease and those who have IgM positive result detected by enzyme (linked) immunoassay. Screening must be done prior to pregnancy. Strict collaboration between professionals of different medical specialties is necessary.

[Clostridium difficile infection: epidemiology, disease burden and therapy]

INTRODUCTION

C. difficile causes 25 percent of the antibiotic associated infectious nosocomial diarrhoeas. C. difficile infection is a high-priority problem of public health in each country. The available literature of C. difficile infection's epidemiology and disease burden is limited.

AIM

Review of the epidemiology, including seasonality and the risk of recurrences, of the disease burden and of the therapy of C. difficile infection.

METHOD

Review of the international and Hungarian literature in MEDLINE database using PubMed up to and including 20th of March, 2012.

RESULTS

The incidence of nosocomial C. difficile associated diarrhoea is 4.1/10 000 patient day. The seasonality of C. difficile infection is unproved. 20 percent of the patients have recurrence after metronidazole or vancomycin treatment, and each recurrence increases the chance of a further one. The cost of C. difficile infection is between 130 and 500 thousand HUF (430 € and 1665 €) in Hungary.

CONCLUSIONS

The importance of C. difficile infection in public health and the associated disease burden are significant. The available data in Hungary are limited, further studies in epidemiology and health economics are required.

[Antimicrobial therapy of Clostridium difficile infection. Systematic review and meta-analysis of the scientific evidence]

INTRODUCTION

Clostridium difficile is the leading cause of antibiotic associated infectious nosocomial diarrhoea. Limited number of new pharmaceutical products have been developed and registered in the past decades for the treatment of Clostridium difficile infection. The available scientific evidence is limited and hardly comparable.

AIM

To analyse the clinical efficacy and safety of metronidazole, vancomycin and fidaxomicin in the therapy of Clostridium difficile infection.

METHODS

Systematic review and meta-analysis of the literature data.

RESULTS

Meta-analysis of literature data showed no significant difference between these antibiotics in clinical cure endpoint (odss ratios: fidaxomicin vs. vancomycin 1.19; vancomycin vs. metronidazol 1.69 and fidaxomicin vs. metronidazol 2.00). However, fidaxomicin therapy was significantly more effective than vancomicin and metronidazol in endpoints of recurrence and global cure (odds ratios: fidaxomicin vs. vancomycin 0.47; vancomycin vs. metronidazol 0.91 és fidaxomicin vs. metronidazol 0.43). There was no significant difference between fidaxomicin, vancomycin and metronidazole in safety endpoints.

CONCLUSIONS

Each antibiotic similarly improved clinical cure. Fidaxomicin was the most effective therapeutic alternative in lowering the rate of recurrent Clostridium difficile infections.

[Observations on human parvovirus B19 infection diagnosed in 2011]

INTRODUCTION

The incidence of human parvovirus B19 infection is unknown.

AIM

A retrospective analysis of clinical and laboratory findings was carried out in patients diagnosed with human parvovirus B19 infection in 2011 in a virologic laboratory of a single centre in Hungary.

METHODS

Clinical and laboratory data of patients with proven human parvovirus B19 infection were analysed using in- and out-patient files.

RESULTS

In 2011, 72 patients proved to have human parvovirus B19 infection with the use of enzyme immunoassay. The clinical diagnoses of these patients were as follows: human parvovirus B19 infection (30.6%), transient aplastic crisis (16.7%), arthritis (8.3%) and acute hepatitis (4.1%). Symptoms of each of the four phases of the infection occurred in various combinations with the exception of the monophase of cheek exanthema. This occurred without the presence of other symptoms in some cases. Leading symptoms and signs were exanthema (in 74.6% of cases), haematological disorders (in 69% of cases), fever (in 54.9% of cases) and arthritis (in 33.8% of cases). Several atypical dermatological symptoms were also observed. Acute arthritis without exanthema was noted in 8 patients. Of the 72 patients with proven human parvovirus B19 infection there were 7 pregnant women, and one of them had hydrops foetalis resulting spontaneous abortion. In 16 patients (22.5%) human parvovirus B19 IgG was undetectable despite an optimal time for testing.

CONCLUSION

The observations of this study may contribute to a better recognition of clinical symptoms of human parvovirus B19 infection.

Characteristics of nosocomial bloodstream infections at a Hungarian cardiac surgery centre

Nosocomial bloodstream infection (BSI) is a common finding in cardiac surgery intensive care units and is associated with excess mortality and hospital costs. Additional data are needed about incidence, characteristics, predictors, associated microorganisms of nosocomial BSI in cardiac surgical patients in order to refine measures to prevent nosocomial infections and to improve recovery outcomes in this patient population. The 3912 cardio-thoracic surgery patients from all age groups were admitted to the study at the Gottsegen György Hungarian Institute of Cardiology between January 1999 and December 2000. In each patient with BSI demographic, epidemiological and clinical variables were recorded along with potential risk factors. Incidence of associated pathogens and their possible sources were evaluated and outcome and mortality risk factors were assessed. There were a total of 134 episodes of BSI. The incidence was 34.25 per 1000 admissions. The leading microorganisms were staphylococci (37.7%). Bacteremic episodes developed secondary to an identifiable source in 27.6% of the cases, or were catheter-related (16.4%). In 56% of the cases the source was not identified. The crude mortality rate was 33.3%. Higher mortality rate was associated with intracardial grafts (p < 0.05), low left ventricular ejection fraction (p < 0.04), diabetes mellitus (p < 0.05), an age above 16 years (p < 0.02), severe sepsis (p < 0.001) and high APACHE II score (p < 0.001). As the identified main sources of BSI were intravascular lines, mortality from BSI could probably be reduced by paying more attention to the prevention, early recognition and prompt management of intravascular device associated infections.

[Case of a diabetic man cured of rhinocerebral zygomycosis]

Zygomycosis (mucormycosis) is a rare, highly aggressive opportunistic fungal disease caused by saprophytic fungi, belonging to the division Zygomycota, class Zygomycetes. Patients with immunodeficiency, neutropenia, iron overload, hematological malignancies, as well as diabetics with ketoacidosis are typically affected.

CASE PRESENTATION

Authors describe the case of an eighteen-year old man with poor compliance suffering from diabetes since the age of nine. He was admitted with ketoacidotic somnolence in severe general condition with unilateral periorbital erythematous edema. Though from nasal exudates gained by the fibero-endoscopic sinus surgery Methicillin-resistant Staphylococcus aureus and Pseudomas aeruginosa was cultured, amphotericin-B was administered as the medical history, clinical picture suggested presence of zygomycosis. An invasive infection caused by Rhizopus oryzae was confirmed by histology and microbiology.

DISCUSSION

The combination of antifungal therapy, repeated surgical interventions and granulocyte colony-stimulating factor resulted in good clinical response. Four month after discharge he is alive and doing well.

Characterization of ryanodine receptors in rat colonic epithelium

AIM

Functional evidence suggests the presence of two types of intracellular Ca(2+) channels responsible for the release of Ca(2+) from Ca(2+)-stores, i.e. inositol-1,4,5-trisphosphate (IP(3)R) and ryanodine receptors (RyR), in rat colonic epithelium. Generally, three ryanodine receptor isoforms (RyR1-RyR3) are known; however, the type of RyR at this epithelium is unknown and was the focus of the present study.

METHODS

RyRs were characterized by molecular biological and immunohistochemical methods in the rat colon.

RESULTS

A transcript of RyR1 was found in mRNA from colonic crypts. In contrast, RyR2 and RyR3 were found in their corresponding reference tissues, but not in the cDNA from colonic crypts suggesting a predominant expression of the RyR1 isoform in this epithelium. In order to characterize the subcellular localization of RyR1, immunohistochemical experiments were performed. They showed that RyR1 is present in the lamina epithelialis mucosae and smooth muscle cells and is distributed equally along the whole crypt axis with no difference between surface and crypt cells. A double staining with IP(3)R3, the dominant cytoplasmic isoform of IP3Rs in this epithelium, revealed that there is only little colocalization of the two receptor subtypes within the epithelial cells. Furthermore, the epithelium is equipped with the enzyme CD38 responsible for the production of cyclic adenosine diphosphate ribose, the physiological agonist of RyR. RyRs are known to be activated by changes in the redox state. The oxidant, monochloramine evoked a ruthenium red-sensitive Ca(2+) release all over the crypt axis. This release was unaffected by prior stimulation of IP(3) receptors with ATP (and vice versa).

CONCLUSION

The present data suggest a functional separation of IP(3)- and ryanodine receptor-carrying Ca(2+) stores in the colonic epithelium.

[Role of transoesophageal echocardiography in bacteremia caused by Staphylococcus aureus]

Treatment and prognosis of bacteremias caused by Staphylococcus aureus is different, whether only bacteremia is present or it is complicated with endocarditis. Transoesophageal echocardiography may have a role in evaluation of bacteremias caused by Staphylococcus aureus to confirm or exclude infective endocarditis. The aim of this study was to characterize patients with infective endocarditis.

PATIENTS AND METHOD

We reviewed the patients studied with transoesophageal echocardiography at our institute between October 1988 and March 2002. The reason for transoesophageal echocardiography was bacteremia caused by Staphylococcus aureus. A total of 24 patients data were analyzed, 15 male and 9 female. Suspicion of infective endocarditis was in 11 patients with native valves, in 8 patients early after prosthetic valve implantation, in 2 patients late after prosthetic valve implantation and in 3 patients after pacemaker implantation. Patient's data were analyzed retrospectively.

RESULTS

Thirteen patients had infective endocarditis and 7 of them had community acquired infection. Native valve, prosthetic valve and left ventricular thrombus were the infected tissues. Vegetation was present in 11 patients, one of them was infection of the left ventricular thrombus. Paravalvular leak was found in 3 patients and abscess in 2. Three out of 7 patients with native valve infective endocarditis presented on a structurally normal valve. Eleven patients had no infective endocarditis, in 9 of them there was nosocomial bacteremia. Surgery was performed in 8 patients with infective endocarditis: 3 with acute, 3 with subacute and 2 with late infection. Two patients died after surgery, one of them had acute infection. Four medically treated patients were cured and one died. From the 11 patients without infective endocarditis 7 were cured and 4 died. At the autopsy infective endocarditis was diagnosed in one out of 4 patients. Transoesophageal echocardiography was performed in this patient 4 weeks before death.

CONCLUSION

The authors' date suggest, that transoesophageal echocardiography is the diagnostic tool for differentiation between bacteremia and infective endocarditis. The infective endocarditis in both community acquired and nosocomial Staphylococcus aureus bacteremia can cause infective endocarditis on native valves, in thrombus and on intracardiac materials.

[A case of femoral osteomyelitis caused by Lactococcus]

The authors report on a case of osteomyelitis of the femur, where the causative agent was Lactococcus. These bacteria are mainly pathogenic in endocardial implants and extremely rare in osteomyelitis. The osteomyelitis was complicated with endocarditis, cerebral and pulmonary abscess. In the reported case the occurrence of osteomyelitis was similar to bone tumor formation, so there was a challenging diagnostic approach. Based upon this case, the diagnostic algorithm, the treatment strategy and the outcome of the treatment are reported. Authors also give a short overview of the literature published on this rare microorganism in bone and joint diseases.

[Detection of lactoferrin in feces for differential diagnosis in diarrhea]

INTRODUCTION

Routine stool culture is used to evaluate patients with diarrheal illness. However, the results are often delayed, and the tests are very expensive. Therefore a rapid, simple method for screening would be a helpful adjunct in a diagnostic algorithm. Fecal leukocytes are found in diarrhea patients with diffuse colonic inflammation but missing in non-inflammatory cases, and are most commonly identified in infectious diarrheas of bacterial origin. It supports the use of immediate empiric therapy in very young, elderly and immunocompromised individuals. When negative, it may eliminate the need for stool culture in some cases of diarrhea. Recently, a new latex bead assay has been developed for the detection of lactoferrin, an iron binding glycoprotein found in polymorphonuclear leukocytes.

AIMS

Evaluate the value of fecal leukocytes and lactoferrin in the workup of patients with diarrhea.

METHODS

Fecal samples of 50 consecutive adult patients with acute or chronic diarrhea were tested for fecal leukocytes and lactoferrin. The results were compared with findings from fecal cultures, tests for parasite, Clostridium difficile A toxin latex test, data of the gastrointestinal examination and clinical evaluation. The authors defined two groups of the cases: the inflammatory and non-inflammatory diarrheas.

RESULTS

The sensitivity, specificity, positive and negative predictive value of microscopic leukocyte count and the lactoferrin test were 42 and 63%, 87 and 87%, 67 and 75%, 71 and 79% respectively.

CONCLUSIONS

In agreement with the literature the results of the present study indicate that fecal lactoferrin appears more sensitive than fecal leukocyte smear, and accurately rules out inflammatory diarrhea.

[Adult-onset Kawasaki syndrome in the differential diagnosis of liver disease]

The authors present a case of an adult with Kawasaki syndrome, who, due to jaundice, enlarged liver and abnormal liver function tests, was admitted the hospital with the suspicion of liver disease. The symptoms of Kawasaki syndrome appeared during the first nine days of the hospital stay. The authors emphasise, that liver function tests are frequently abnormal in adults presenting with this clinical entity, therefore Kawasaki syndrome should be taken into consideration in the differential diagnosis of liver diseases.

Analysis of Ir in Köfelsit rocks by inductively coupled plasma-sector-field mass spectrometry (ICP-SFMS)

Three different analytical strategies have been evaluated for the quantification of Ir in geological samples. Glassy rock samples from Köfels and reference material WGB-1 were analyzed directly by inductively coupled plasma sector field mass spectrometry (ICP-SFMS) at mass resolution 400 using membrane desolvation and at mass resolution 9500 without membrane desolvation. Matrix separation by anion-exchange pre-concentration was also investigated. The ultrasonic nebulizer USN6000AT+ (Cetac Technologies, Omaha, NE, USA) incorporating a membrane desolvation unit was used as the sample-introduction system. Sample preparation involved complete microwave-assisted acid digestion of the silicate matrix with HNO3-HCl-HF. The results obtained by the three methods of quantification were in good agreement, showing that oxide-type interferences were effectively eliminated solely by membrane desolvation. The limits of detection were 6 pg g for low resolution measurement with use of the membrane, 15 pg g(-1) at a mass resolution of 9500, and 59 pg g(-1) for the ion-exchange procedure. The ultimate precision obtained for the Köfelsit Ir data was, however, compromised by the small sample intake (0.3 g), because of the inhomogeneous distribution of Ir in geological samples.

[Successful treatment of acute ethylene glycol poisoning with plasmapheresis]

The authors show the differential diagnostics, therapy and patomechanism of the ethylene glycol intoxication in connection with review of their young patient became acute paraparetical in consequence of the intoxication. In the therapy of the ethylene glycol intoxication, instead of the traditionally proved hemodialysis their patients was treated with great efficiency with plasmapheresis. The authors show the patomechanism of a patient came with atypical Guillain-Barré-Syndrome. In the hinterground of an acute paraparesis was an ethylene glycol intoxication identified. In the therapy of this intoxication their patients was treated with great efficiency with plasmapheresis instead of the traditionally proved haemodialysis. They touch upon the possibility of monitoring with gas chromatography of the patients plasmapheretised, and call attention the easy check of the sodium fluorescein content of the antifreeze additive therefore the rapid recognition of the intoxicated status.

[Successful meropenem therapy of recurrent multiple brain abscess]

Authors describe the history of a 37-year-old man suffering from multiple purulent brain abscess. The multiple brain abscess evolved primarily from a gluteal abscess to the lung, and secondarily from the lung to the brain by hematogenous spreading of the bacteria. The identification of the pathogene/s was unsuccessful despite numerous bacteriological examination. Despite many regimens of empiric antibacterial therapy the brain abscesses progressed, neurologic state of the patient deteriorated. At long last, the patient was given chloramphenicol. After that, he had no more fever, his consciousness cleared, no more epileptic convulsion occurred and the cell number of the cerebrospinal fluid became normal. The patient was thought to be cured and was sent home. Two months later fever occurred again and it was accompanied by excrutiating headache, increasing disorientation, so the patient was admitted to the hospital. The occurrence of a new brain abscess and purulent meningitis indicated the relapse of the disease. It was again unsuccessful to identify the pathogene/s therefore the authors treated the patient with many empiric antibiotic regimen, all of which-including chloramphenicol too--proved to be uneffective. As all the therapeutic regimens usually used in the treatment of purulent brain abscess were uneffective--including the combinations which have the widest antibacterial spectrum, authors gave meropenem as ultimum refugium. Some days later the fever came to an end, his consciousness cleared, the brain pressure and the cerebrospinal fluid became normal. The patient had no serious complaints in the course of the four years follow up, his residual neurologic symptoms regressed. On the base of this case history, authors suppose that meropenem--which has already proved to have a very wide antibacterial spectrum and to be very effective in the therapy of many kinds of serious bacterial infections--could also become a promising new therapeutic alternative in the treatment of purulent brain abscess.

[Opportunistic systemic mycoses]

Systemic fungal infections can be primary or opportunistic. The mycoses caused by opportunistic pathogens become increasingly more important. These infections are mainly caused by Candida species, Aspergillus species, Cryptococcus neoformans, Mucor etc. The predisposing factors to these diseases are numerous: neutropenia, organ transplantation, use of steroids, broad spectrum antibiotics, antineoplastic chemotherapy, parenteral nutrition, prolonged intravenous infusions, extensive surgery etc. Mortality is high because many fungal infection are difficult to diagnose, especially in their early, more treatable stages. Considerable progress in treating these infections has been achieved. Systemic fungal infections, however, continue to present major problems, including clinical resistance, microbial resistance, emergence of new pathogens and involvement of more susceptible patients. The purpose of this paper is to review the recent progress and current problems in diagnosis, treatment and prevention of opportunistic systemic fungal infections.

Activity of intracellular antibiotics

We have studied the intracellular bioactivity of several antimicrobial agents against two strains of Staphylococcus aureus, a pathogen sequestrated in phagolysosomes, using peripheral blood neutrophils from human volunteers. This was compared to the activity of cell-associated drugs also measured in vitro. Several discrepancies (high cellular association, low bioactivity) were observed (coumermycin, glycopeptides, erythromycin and clindamycin) which can be due to the binding of the drug to a particular cellular organelle, to intracellular metabolization or inactivation, to unfavourable conditions in the phagolysosome (pH drop), or to a toxic effect of the drug on the functions of the neutrophil. Addition of the antibiotic during ingestion was frequently associated with better neutrophil-dependent killing through several potential mechanisms: coingestion of the antibiotic with the inoculum, modification of opsonization, release of activating substances and fragilization of the microorganism to oxygen-dependent or -independent killing mechanisms.

[Hypereosinophilia syndrome of unknown origin]

The authors describe the case of a 19-year-old man with hypereosinophilic syndrome. At first the clinical picture suggested a localized eosinophilic gastrointestinal disease which rapidly progressed to the fatal disseminated form. The spectrum of hypereosinophilic syndrome is discussed and current thoughts on diagnosis, pathology and treatment presented.

[Imported food poisoning caused by fish toxins (ciguatoxin)]

Various types of fish-poisoning mainly occur in tropical areas. Saxitoxin, tetrodotoxin, scombrotoxin and clupeotoxin are heat labile while ciguatoxin, in contrast, is heat stable thus it may be the source of severe poisoning even in case of thorough cooking and baking. In December 1987 a mass alimentary poisoning occurred following ingestion of fish meat in a group returning from Cuba. The most severe case was admitted to our department with symptoms of extended paresis. Diagnosis of ciguatoxin poisoning was established based upon the history, clinical features and laboratory results. Nowadays exotic, remote "Fish-poisoning" cases have to be taken into consideration even in our country.

[Isolation of Corynebacterium JK from the blood of neutropenic patients with septic diseases]

The authors report on the isolation of Corynebacterium JK from the blood of two neutropenic patients with hematological malignancy. In Hungary this paper is the first to discuss the microbiology of the organism and clinical manifestations of the group JK Coryneform infection. The clinical significance of this organism in the nosocomial infections of compromised patients and the association of the infection with the use of plastic devices has been emphasized. The sensitivity of the multiresistant coryneform bacterium to vancomycin may help to make the microbiological diagnosis and to select the drug for therapy.

[Granulomatous hepatitis in cytomegalovirus infection]

Authors report the serologically verified CMV hepatitis of a 35-year old man whose hepatic alteration appeared in the form of a granulomatous hepatitis. On this account the characteristics of granulomatous hepatitis cases published so far in the literature are surveyed.

Ceftriaxone versus cefotaxime in the treatment of septicemia in adults

Two potent third-generation cephalosporins with similar antibacterial spectra but different pharmacokinetics were compared in patients suffering from septicemia due to different organismus. Sixty patients with a variety of underlying diseases were included in the study. They received either 2-4 g ceftriaxone (active ingredient of Rocephin) once a day or 2 g cefotaxime every 8 h for 10-15 days. Our data confirm that a single dose of 2 g ceftriaxone should be sufficient to treat septicemia.

Meningitis caused by Gordona aurantiaca (Rhodococcus aurantiacus)

In a case of hairy cell leukemia, Gordona aurantiaca (Rhodococcus aurantiacus) was isolated from cerebrospinal fluid as the pathogen responsible for lethal infection of the central nervous system. The pathogen had been isolated previously from one case of pulmonary infection process only.