Showing papers in "Acta medica Croatica : c̆asopis Hravatske akademije medicinskih znanosti in 2003"

[Prevalence of symptoms of asthma, allergic rhinitis, conjunctivitis and atopic eczema: ISAAC (International Study of Asthma and Allergies in Childhood) in a population of schoolchildren in Zagreb]

Abstract: OBJECTIVE: Numerous studies of the population prevalence of asthma, allergic rhinitis, and atopic eczema revealed some international differences. However, the International Study of Asthma and Allergies in Childhood (ISAAC) was the first one using a standardized methodology to evaluate the prevalence of these diseases, and to make comparisons within and between countries. The results showed marked variations in 12-month prevalence of asthma, allergic rhinoconjunctivitis, and atopic eczema symptoms with 20-fold (range 1.6-36.8%), 30-fold (range 1.4-39.7%), and 60-fold (range 0.3-20.5%) differences between the centres with the highest and the lowest prevalence, respectively. AIM: Our aim was to gain the insight into the prevalence of allergic diseases in Zagreb, Croatia by the methods of internationally standardized protocol, proposed by the ISAAC Steering Committee. METHODS: Original questionnaires, translated from English into Croatian, consisting of questions about the child's demographic characteristics, core modules on wheezing, rhinitis and eczema, and supplementary modules, were completed by parents of 10-year-old children (4th grade) attending 18 elementary schools in a city of Zagreb. Total of 1047 questionnaires were returned and analysed after the inconsistent responses were eliminated by phone calling. DISCUSSION: Phase one of the ISAAC study has shown a wide variation in the prevalence of asthma, allergic rhinoconjunctivitis, and atopic eczema symptoms throughout the world, with differing international patterns for the different disorders. Four prevalence ranges have been established for better illustration of the geographic distribution of asthma prevalence: (I) or = 20%. The highest 12-month prevalences of asthma symptoms were found in developed countries (UK, Australia, New Zealand, Republic of Ireland, and most centres in North, Central, and South America), being in prevalence range IV. The lowest prevalences (range I) were found in several Eastern European countries, Indonesia, Greece, China, Taiwan, Uzbekistan, India, and Ethiopia. According to the results of our study, a continental part of Croatia with a 12-month prevalence of wheezing of 6.02% corresponds to range II. Prevalence of asthma symptoms was greater in males, which is consistent with the results of the younger age group previously analysed. For allergic rhinoconjunctivitis and atopic eczema symptoms grouping of centres with a high prevalences into specific regions was less well defined than for asthma. Centres with the highest prevalences were scattered across the world. In contrast, centres with the lowest prevalences were similar to those for asthma symptoms. Our results of the 12-month prevalence of allergic rhinoconjunctivitis (12.13%), and atopic eczema (7.83%) symptoms were somewhere between the two extremes. As with asthma symptoms, the prevalence of rhinoconjunctivitis symptoms was greater in males. Contrary, the difference in prevalence of atopic eczema symptoms between the sex groups has not been found. The worldwide variations in prevalence of asthma, allergic rhinoconjunctivitis, and atopic eczema symptoms suggest that environmental factors may be critical to the development of these disorders in childhood. Furthermore, different patterns of geographical distribution of particular disorders suggest that major risk factors for them may be different or may involve different latency periods and time trends. Therefore, studies that include objective clinical assessment are required. CONCLUSION: According to our results, Zagreb is a city with relatively low prevalence of allergic diseases symptoms. Larger sample size of at least 3000 subjects is required to provide sufficient precision for estimates of symptom severity, and to generate adequate number of subjects with particular disorders for further analyses. Therefore, we recently increased our sample size to more than 3000 subjects, and started ISAAC Phase two (clinical examination, measures of bronchial hyperresponsiveness, measures of atopy, measures of environmental exposure to aeroallergens, and genetic analyses) in Zagreb, Croatia.

[Laparoscopic cholecystectomy--accessory bile ducts].

Abstract: Introduction Modern medical technology (ultrasonography, intraoperative radiologic contrast methods, ERC, CT and NMR) help in performing laparoscopic cholecystectomy and operative procedures on bile ducts. The safe performance of these operative procedures requires good knowledge of clinical anatomy. In spite of excellent laparoscopic visualization, perioperative lesions of vascular structures or extrahepatic (especially accessory) bile ducts during laparoscopic cholecystectomy are a frequent cause of intra- and postoperative complications. Therefore, we wish to point to the potential risk of running into accessory bile ducts on dissection within or around the cystohepatic triangle, which may entail some overlooked and untreated lesions. Patients and method Accessory bile ducts originate from the liver parenchyma and may enter a large bile duct or gallbladder at any location, or can directly enter the intestine. The accessory bile ducts encountered on cholecystectomy or bile duct procedure call for special attention. We found accessory bile ducts in 13 (0.52%) patients during the procedure of laparoscopic cholecystectomy. There are three groups of 'risky' accessory bile ducts that can be encountered during laparoscopic cholecystectomy. Group I includes accessory bile ducts encountered on gallbladder removal from its support: 1) Luschka's subvesical accessory bile duct was found in six (46.1%) patients. A lesion to these ducts was intraoperatively observed in three (23.1%) patients, whereas in another three (23.1%) patients it was only detected and treated on reoperation; 2) the hepatocystic bile duct enters gallbladder directly from liver parenchyma, in the area of the gallbladder lobe. A hepatocystic accessory bile duct was identified during one (7.7%) laparoscopic cholecystectomy, when the duct lumen was observed on the gallbladder removal from the lobe, and another one (7.7%) was only identified on reoperation. Group II comprises accessory bile ducts encountered during dissection in the cystohepatic triangle, between the two hepatovesical plicae: 1) the hepatocystic accessory bile duct runs from liver parenchyma into the cystic duct within the cystohepatic triangle. Bile leak from a bile duct approaching the cystic duct immediately below the clip was observed on reoperation in one (7.7%) patient; 2) the hepatohepatic accessory bile duct drains a part of the liver and runs into the common hepatic duct within the cystohepatic triangle. During one (7.7%) dissection, another delicate bile duct originating from liver parenchyma was detected upon cystic duct clipping. Bile leak from a bile duct running into the common bile duct before entering the properly occluded cystic duct was observed on one (7.7%) reoperation; 3) anastomotic accessory bile ducts connect cystic duct with the common hepatic duct, or connect gallbladder, which has its own cystic duct, with the common hepatic duct or right hepatic duct. In our laparoscopic practice, we did not encounter this type of accessory bile ducts. Group III includes accessory bile ducts observed in the laparoscopic operative field, beyond the cystohepatic triangle, during cholecystectomy and bile duct procedures: 1) the hepatocystic accessory bile duct leaves liver parenchyma and enters the gallbladder at various sites. Stumps of two such accessory bile ducts (15.4%) were detected on reoperation. One entered the gallbladder below the cystic duct entry, and the other approached the gallbladder from above. Results Reoperation following laparoscopic cholecystectomy was required in 15 (0.6%) patients. In eight (53.3%) of these, the reason for reoperation was untreated lesion of accessory bile duct in eight (53.3%), other untreated minor lesions of the cystic duct in five (33.3%), and lesions of the hepatocystic duct in two (13.3%) patients. Out of the eight patients reoperated on for untreated lesion of accessory bile duct, reoperation was indicated by external biliary secretion by drain for more than 7 days in three (37.5%), and by the development of biliary peritonitis with the symptom of pain in five (62.5%) patients. Right-sided shoulder pain and elevated body temperature were recorded in two (40.0%) patients each, whereas abdominal distension with pronounced local defense and hyperbilirubinemia were observed in four (80.0%) patients each. A combination of these symptoms was present in the majority of patients. The prevalence of symptoms was consistent with literature reports. Of the eight patients reoperated on for lesions of accessory bile ducts, the lesion was managed by repeat laparoscopy procedure in five (62.5%) and by laparotomy in three (37.5%) patients. There was no mortality. Conclusion Besides technical skill and experience, good knowledge of the clinical anatomy of accessory bile ducts is required to reduce the incidence of postoperative biliary secretion. Based on our own experience, lesions to accessory bile ducts are the most common cause of postoperative complications.

Prevalence of psoriatic arthritis in a population of patients with psoriasis

Abstract: UNLABELLED Psoriatic arthritis (PsA) is a chronic inflammatory rheumatic disease characterized by arthritis associated with psoriasis. AIM OF THE STUDY The aim of the study was to determine the prevalence of psoriatic arthritis in a population of patients with psoriasis. According to literature data, its prevalence varies between 1% and 7%, or only exceptionally more. PATIENTS Seventy-two adult patients with psoriasis were examined. Patients came from the north-west part of Croatia, from different towns with the overall population of more than 150,000, thus making a representative epidemiological sample. Some patients were treated by a dermatologist, whereas others were admitted to rheumatology departments for the problems with locomotor system and were diagnosed as psoriatics. All patients were examined, and their data were processed. RESULTS Statistical analysis showed the two sexes to be equally involved by psoriasis. In most cases psoriasis preceded arthritis. All arthritis patients had their fingernails affected with psoriasis. In the population of patients with psoriasis, the prevalence of arthritis was higher in men (60%) than in women (40%). Arthritis often occurred (37.5%) in patients with psoriasis localized in the inguinal and/or perianal region with toenail involvement, as compared to 8.9% of patients with arthritis without concurrent psoriasis involvement. CONCLUSION The prevalence of arthritis in psoriasis patients was 15.3%.

The biggest epidemic of hemorrhagic fever with renal syndrome in Croatia

Abstract: Introduction The largest outbreak of hemorrhagic fever with renal syndrome (HFRS) to date occurred in Croatia in the year 2002. The epidemic started in winter, lasted throughout spring to summer months, ending not earlier than November. Aim The aim of this study was to investigate and analyze the basic epidemiologic and clinical features of HFRS in Croatia by uniform and standardized prospective-retrospective analysis of all patients affected by the epidemic. Patients and methods When the epidemic started, a patient questionnaire with questions on the basic demographic data, site of infection and other epidemiologic characteristics, clinical symptoms, disease severity and laboratory results was designed. Data on 401 patient with a clinical diagnosis of HFRS were collected. The etiologic diagnosis of the disease was confirmed by ELISA, and in some patients by indirect immunofluorescence test (IFT). The results were analyzed using a descriptive statistical method. Results HFRS was clinically diagnosed in 401 patients from all over Croatia. A total of 320 (79.8%) cases were reported to the Epidemiology Service of the National Institute of Public Health. The majority of patients (n = 128) were registered in June. Males were three times more affected than females. Apart from its long duration, this epidemic was characteristic for the involvement of general population, with only a small number of the affected from the potential risk groups (forestry workers 28, soldiers 14, farmers 18). The epidemic spread almost throughout inland Coratia. At least 44 patients were infected in the Plitvice Lakes area, 32 in Slunj, 27 on Sljeme, 24 in Velika, and at least 19 in the area of Kutjevo. The youngest patient was aged 4 and the oldest 80 years. The majority of patients were treated in Zagreb (University Hospital for Infectious Diseases--110, Zagreb University Hospital Center--3), followed by Karlovac (71 inpatients and 39 outpatients), Pozega (n = 79), and Rijeka (n = 37). Serologic analysis (ELISA method) detected Puumala virus in 161 and Dobrava virus in only 17 patients. The disease was confirmed by immunofluorescence method in 53 patients (mostly in Kariovac). During the 2002 outbreak, HFRS clinically manifested mostly in a milder form with general symptoms and transitory renal insufficiency, while hemorrhages were rarely recorded. According to our disease severity score, a mild form of the disease was recorded in 65%, moderately severe in 28%, severe in 5% and extremely severe form in 2% of the patients. One patient died. Two thirds of the patients were hospitalized during the febrile stage of the disease. All patients had fever, whereas headache and pain in the lumbar region were recorded in more than 90% of cases, polyuria in 75%, oliguira and vomiting in approximately 50%, respiratory symptoms in 35%, and hemorrhages (mostly on the skin and mucous membranes), vision disturbances, conjunctivitis and diarrhea in approximately 25% of patients. ESR was elevated in 64% and CRP in 93% of patients. Leukocytosis was recorded in 25% and thrombocytopenia in 70% of patients. Increased values of urea and creatinine and signs of liver damage were recorded in approximately 50% of the patients. Conclusion The largest outbreak of HFRS occurred in Croatia in 2002, with more than 400 diseased throughout Croatia. This epidemic confirmed our previous assumption that the whole Croatia, apart from its narrow coastline area and islands, is a natural focus of HFRS with different causative types of hantaviruses. Efforts should be made to conduct a comprehensive ecologic and mammologic study on hantaviruses and their biologic characteristics in these areas.

Changes in autonomic control of heart rate after ischemic cerebral stroke

Abstract: BACKGROUND AND PURPOSE Heart rate variability (HRV) is a physiological phenomenon which reflects the influence of the autonomic nervous system on the heart work The research in HRV has not been limited to the domain of basic and clinical cardiology, mostly with the aim of stratifying the risks of sudden death from malignant arrhythmias among patients with myocardial infarction (MI), but over the past few years the research has been done and studies have been published also in the area of neurology Likewise acute MI, acute ischemic stroke leads to autonomic dysbalance and lowered HRV However, literature lacks relevant data on autonomic dysbalance after the acute phase of ischemic stroke The aim of this study was to assess the level of autonomic dysbalance in patients after the acute phase of ischemic stroke PATIENTS AND METHODS This prospective study included 86 consecutive patients who had suffered ischemic stroke (59 men and 27 women, mean age 56 +/- 13 years) and 86 age-matched healthy control subjects (62 men and 24 women, mean age 53 +/- 9 year) In the acute phase of the disease, along with clinically manifest neurologic deficit, there is ischemic hemispheric lesion verified by computed tomography (CT) scan Lesion of the left and right cerebral hemisphere was detected in 56% and 44% of patients, respectively After the acute phase of the disease, patients were hospitalized at one of the neurologic departments of the Hospital for Medical Rehabilitation in Krapinske Toplice, Croatia, where rehabilitation was carried out (mean duration 20 +/- 9 days) in the 1999-2002 period Inclusion criteria were: age under 70 years, first ischemic stroke verified by CT scan within 2-12 weeks of the acute phase of the disease, Barthel index 30-50, and stable sinus rhythm in ECG Exclusion criteria were: a history of previous ischemic stroke, intracerebral hemorrhage, MI, percutaneous coronary intervention or surgical revascularization of the myocardium, clinical signs of coronary artery disease, acute heart failure, diabetes mellitus, chronic atrial fibrillation, sinus node disease, AV block grade II or III, and the use of beta adrenergic blockers or antiarrhythmic agents class Ic or III in medication Twenty-four hour Holter ECG was performed 58 +/- 23 days after the stroke (14 +/- 5 days from the beginning of rehabilitation) HRV was analyzed from the Holter ECG data The values of the HRV parameters in stroke patients were compared with those recorded in the control group Most of the variables proposed by the Task Force on HRV were analyzed Time domain analysis included: mean RR, mean of R-R intervals for normal beats; SDNN, standard deviation of all normal R-R intervals; SDNN-i, mean of 5-minute standard deviations of RR intervals; SDANN-I, standard deviation of the 5-minute means of R-R intervals; rMSSD, square root of the mean of the squared successive differences in R-R intervals; and pNN50, percentage of R-R intervals that are by at least 50 ms different from the previous interval Frequency domain analysis included: TP, total power (00-05 Hz); VLF, very low (00033-004 Hz); LF, low (004-015 Hz); HF, high (015-040 Hz) frequency components; and LF/HF, low to high frequency ratio Statistical analysis was performed using the commercial software package, Microsoft SPSS for Windows, Version 80 RESULTS Patients who had suffered an ischemic stroke had a significantly lower overall HRV and shorter mean RR interval than healthy subjects from the control group: SDNN 96 +/- 27 vs 136 +/- 31 ms, p < 0001; TP 1962 +/- 1338 vs 3968 +/- 2857 ms2, p < 0001; and mean RR 869 +/- 104 vs 892 +/- 117 ms, p = 002 CONCLUSION As in MI, the values of HRV stay significantly lower after the acute phase of the disease in patients who have suffered ischemic stroke compared to healthy persons of the same age

Leiomyosarcoma of the breast

Abstract: A 62-year old patient was treated at our hospital for a palpable change in the upper part of the left breast. The clinical finding was preoperatively confirmed by radiologic, ultrasound and cytology studies, however, the potential biologic process (malignant/benign) was not thus verified. Considering undefined diagnostic nature of the process, biopsy, pathohistology and immunoanalysis were performed to indicate leiomyosarcoma mammae. The incision interspace at certain sites was less than two centimeters, indicating radical breast excision in toto (ablation with evacuation of the contents of the axilla). At the time of scheduled surgery, the patient sustained cardiologic discomfort, so tumorectomy was supplemented by locoregional radiotherapy. Leiomyosarcoma of the breast is a very rare primary malignant breast tumor, with only 14 cases reported in the literature. Considering the rare occurrence of leiomyosarcoma of the breast, in radical surgery we used attitudes like in other breast tumors and leiomyosarcoma of other localizations.

Immunopathogenesis of hemorrhagic fever with renal syndrome and hantavirus pulmonary syndrome

Abstract: Hantaviruses (HTV) cause two serious human diseases: hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS), posing a considerable public health problem worldwide. Immunopathogenesis has been suggested to be involved in both HFRS and HPS. A common feature of hantavirus diseases is an increased microvascular bed permeability, suggesting that vascular endothelium is a prime target of virus infection. Although HTV infect numerous cell lines and primary cells, it was considered that they do cause no cytopathic effect. Recently, we found HTV to cause a cytopathic effect and apoptosis in 293 HEK cells. Monocytes/macrophages also represent the important target cells, which may also have an important role in the spread of HTV from the primary site of infection. Both endothelial cells and monocytes/macrophages may act as a rich source of cytokines/chemokines during the infection with HTV and additionally contribute to the HFRS/HPS immunopathogenesis. The main reservoirs of HTV are small rodents which are infected but do not have manifest disease. However, some studies show that T-lymphocytes may play an important role in rodent resistance to infection with HTV. Some clinical studies indicate the important role of pro-inflammatory cytokines in the immunopathogenesis of HFRS/HPS. The efficient anti-hantaviral cell-immune response in patients is mainly due to the generation of cytotoxic T-lymphocytes. Our study also pointed to a decrease in the percentage of total naive (CD45RA) cells and an increase in the percentage of memory cells (CD45RO). Specific IgM antibodies appear at the very beginning of the diseases followed by an increase in specific IgG. Additionally, IgE antibodies have been suggested to play a role in HFRS immunopathogenesis. Immune complexes have been detected in the sera, on the surface of red blood cells and platelets, in urine, glomerull and dermal capillaries of HFRS patients. They may be responsible for increased capillary permeability, vascular injury, platelet lysis and kidney damage. The immunopathologic disorders accompanying HFRS/HPS are complex. As there is no appropriate animal model to investigate HFRS/HPS immunopathogenesis, we mostly rely on in vitro and rare clinical studies. Additional efforts in the research of immunopathogenesis caused by HTV, may contribute to better understanding of HFRS/HPS characteristics and course of disease, and improve the treatment and prevention.

Grading the severity of disease in patients with Puumala or Dobrava virus infections from 1995 to 2000 in Croatia

Abstract: AIM The aim of our study was to evaluate the proposed Croatian scale for grading the disease severity in patients with hemorrhagic fever with renal syndrome (HFRS). The aim was also to determine whether the infection with Dobrava virus (DOBV) in Croatia was associated with a more severe illness than the infection with Puumala virus (PUUV). PATIENTS AND METHODS To evaluate the scale, case records of 62 HFRS patients hospitalized at the University Hospital for Infectious Diseases in Zagreb from 1995 till 2000 were reviewed. ELISA IgM and IgG tests were used for the detection of specific IgM and IgG antibodies to PUUV or DOBV. DISCUSSION HFRS caused by hantaviruses is a zoonotic disease spread worldwide, posing a major public health problem of global dimensions. Recent epidemiologic studies show that almost all parts of Croatia are endemic regions for two hantaviruses, Puumala and Dobrava. The disease severity ranges from subclinical infection to severe illness with fatal outcome. Clinical picture is predominated by fever, myalgia, vomiting, hemorrhagic manifestation, visual impairment and kidney affection. There is still a lack of knowledge concerning all the parameters involved in the disease severity. Besides the type of virus and genetic material, host genes are also associated with the variable clinical course. HLA alleles B8, DR3, and DQ2 are strongly associated with severe outcome of PUUV infection, white HLA B27 allele is associated with a mild course. Whether similar genetic factors also operate in DOBV infection remains to be determined. Recently, a Croatian scale for grading the disease severity was proposed. The disease severity is graded by a scoring system (points attributed to specific clinical symptoms and laboratory findings) as 1--mild, 2--moderate, 3--severe, and 4--very severe. We found 60% of HFRS patients to be infected with PUUV and 40% with DOBV. In our study, 65% of patients infected with PUUV had mild, and 24% moderate disease. Severe and very severe disease was recorded in 11% of PUUV infected patients. In contrast, only 44% of patients infected with DOBV had mild disease, whereas 40% of patients showed a moderate clinical picture. Severe and very severe clinical picture was recorded in 16% of patients with DOBV infection. Statistical analysis showed a significant number of pa (p < 0.01) with PUUV infection to have mild disease, whereas a significant number of HFRS patients infected with DOBV had moderate (p < 0.01) and severe or very severe (p < 0.01) disease. CONCLUSION Our results clearly indicate that in Croatia DOBV infection is associated with a more severe disease than PUUV infection. However, we confirmed previous findings that even PUUV infection could lead to a severe disease. Our initial experience in the evaluation of the proposed grading scale for disease severity demonstrated the proposed Croatian scale to be a useful tool in grading disease severity in patients infected with PUUV or DOBV. Moreover, the proposed scale may also prove highly useful for the prognostic purpose.

Puumala and Dobrava viruses in the northeastern and central regions of Bosnia

Abstract: UNLABELLED Bosnia and Herzegovina has been known as a highly endemic region for Hantavirus infections for more than 50 years. Previous studies have shown that at least two different hantaviruses, the murine Dobrava (DOB) and avricoline Puumala (PUU) viruses, each carried by a different rodent species, have been circulating in the area. However, there is little information on rodent population density fluctuations in Bosnia over the past years as well as on the ratio of Puumala to Dobrava infection in humans. THE AIMS THE AIMS OF OUR STUDY WERE to identify the rodent species which may serve as hantavirus reservoirs in the north-east and central Bosnia; to assess the geographical distribution, density and population dynamics of rodent species in the area; to assess the influence of climatic conditions on the size of rodent population; and to determine the ratio of Puumala to Dobrava infection in humans. METHODS The epidemiologic and epizootic study in the north-east and central Bosnia was conducted during the 8-year period (1995-2003). The average yearly and monthly temperatures, air humidity and precipitation during the study period were analyzed. A total of 381 small rodents were caught during the epidemic years (1995 and 2002), and in-between the epidemic periods (1999 and 2000). The animals were caught by live-traps and identified by morphometric methods. The density of animals was estimated by counting the number of holes per 1000 m2. Sera of 311 patients with clinical signs and symptoms of hemorrhagic fever with renal syndrome (HFRS) were tested for the presence of antibodies reactive to the Dobrava, Puumala and Seoul viruses by using indirect immunofluorescence test (IIF), and IgG and IgM ELIS. Sera of 84 patients were tested using only IIF, and 227 sera were tested by IIF and -capture IgM ELIS tests. RESULTS During the epidemic years, the average monthly temperatures in February were by 4.3 times higher than the average temperatures during the nonepidemic years, which may have influenced the early reproduction of rodents and development of "mouse years". The rodents were identified as: Apodemus flavicollis (n = 139), Apodemus sylvaticus (n = 89), Apodemus agrarius (n = 4), Clethrionomys glareolus (n = 117), Sorex araneus (n = 5), Pytimus subterraneus (n = 23), Mus musculus (n = 1), Mycrotus arvalis (n = 1) and Rattus norvegicus (n = 2). Clethrionomys glareolus was predominant in the regions with the altitude higher than 1160 meters and Apodemus species in the regions with the altitude lower than 670 meters. The rodent population density changes seasonally and cyclically. During the epidemic years, the rodent population density was marked as very high, whereas during the nonepidemic years it was designated from low to moderate. Well-known natural hosts of Hantaviruses (A. flavicolis and C. glareolus) are most widely spread species of small rodents, and the increase in their population is closely related with outbreaks of epidemics of HVBS-a. Puumala virus caused HVBS-a in 49.84% (155/311); Dobrava virus in 23.15% (72/311) of cases, whereas Hantaviruses serotype was not identified in 27.00% (84/311) of cases. Infections caused by Puumala virus were more frequent than the infections caused by Dobrava virus during both epidemic and nonepidemic periods. The proportion of humans infected with Puumala and Dobrava viruses correlated with the number of natural hosts of Hantaviruses in the areas of HVBS outbreaks. The study of the prevalence of hantavirus antibodies in the populations of rodents and humans, which had been under way, should elucidate these relationships.

Leptospirosis and hemorrhagic fever with renal syndrome in northwestern Croatia

Abstract: UNLABELLED Leptospirosis is a worldwide spread zoonosis, therefore being also present in northwest Croatia. It has been recently discovered that hemorrhagic fever with renal syndrome (HFRS) is present throughout Croatia, not just in the previously well known epidemic foci. Because of the similar clinical presentation and epidemiology of the two diseases, it is important to know the exact etiology of the current disease. The aim of this study was to determine the presentation of HFRS in northwest Croatia and possible coinfection in patients with leptospirosis. PATIENTS AND METHODS During the 1988-2000 period, 42 patients with leptospirosis from northwest Croatia were analyzed. Leptospiral infection was confirmed in all 42 patients by microagglutination test. Serology for hantaviruses was done by ELISA test in a few patients with leptospirosis and severe renal failure. RESULTS In the majority of patients (37/42: 88%) acute renal failure was mild or moderate, with creatinine values below 500 mol/l. However, 12% of the patients developed severe acute renal failure, with creatinine values over 500 mol/l. The main therapeutic regime in all patients with leptospiral infection included body fluid replacement (electrolyte and glucose infusions) and antibiotic therapy. In patients with severe acute renal failure, it was necessary to introduce hemodialysis treatment. There was no fatal outcome in our patients. Over the last few years, antibody titers to hantaviruses were assessed by ELISA testing in five patients with leptospiral infection and severe form of acute renal failure, confirming HFRS persistence in northwest Croatia Testing for specific antibodies to hantaviruses has been suggested in all patients with leptospirosis and in whole Croatia, especially in northwest Croatia.

[Spontaneous rupture of the spleen in infectious mononucleosis: case report and review of the literature].

Abstract: Objective Spontaneous splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Abdominal pain is uncommon in infectious mononucleosis, and splenic rupture should be strongly considered whenever abdominal pain occurs. The onset of pain may be insidious or abrupt. The pain is usually in the left upper quadrant. Aim To indicate that infectious mononucleosis is not always the innocent kissing disease, but could be complicated with splenic rupture as a life-threathenig condition. Case-report Our first case is described and a short literature review is provided. We report on the case of a 27-year-old man with infectious mononucleosis who had spontaneous splenic rupture that was successfully managed by splenectomy. On admission, he was febrile (38.5 degrees C) with hepatosplenomegaly, and had a blood pressure of 100/70 mm Hg. Six hours later, the patient complained of increasing abdominal pain. Abdominal ultrasound and computed tomography showed a 16.5 cm heterogeneous splenomegaly with subcapsular hematoma as well as free ascites. Laparotomy confirmed spontaneous rupture of the splenic capsule with active abdominal bleeding. Splenectomy was performed with a good clinical response. Examination of the spleen revealed a ruptured capsule with a subcapsular hematoma. Discussion Infectious mononucleosis is the most common infectious disease to result in spontaneous spleen rupture. The prognosis is favorable when diagnosis is made on time and correct treatment is started immediately. Although splenectomy was advocated as definitive therapy in the past, numerous recent reports have documented good outcomes with non-operative management. Based on the literature review, an approach to the management of a spontaneously ruptured spleen secondary to infectious mononucleosis is suggested. Non-operative management can be successful in hemodynamically stable patients, i.e. in patients with subcapsular hematoma without overt rupture of the capsule to avoid complications of splenectomy (e.g. post-splenectomy sepsis). Conclusion We report on a 27-year-old man with infectious mononucleosis who had spontaneous splenic rupture that was successfully managed by splenectomy.

Subjective general assessment of nutritional status in patients with chronic renal failure and regular hemodialysis

Abstract: PATIENTS AND METHODS The protein energy malnutrition rating has been investigated in 75 hemodialysis (HD) patients with average treatment period of 67.3 month. A method of subjective global assessment (SGA) of nutritional status was used including body weight and food intake changes evaluated in last six months, as well as the nutritional status in relation to the subcutaneous fat loss and muscle mass wasting. SGA classifies the patients as: A well-nourished, B--mildly malnourished and C--severely malnourished. RESULTS Malnutrition was identified in 40%, mild in 34.7% and severe in 5.3% of the patients. In the group of patients with normal nutritional status there were significantly fewer patients with lower values of objective parameters of nutritional status (body mass index (BMI), mid-arm muscle circumference (MAMC), phase angle from bioimpedance measurement, serum albumin) than in the group of patients with severe malnutrition. The differences in these parameters were of marginal significance between the groups with normal nutritional status and with mild malnutrition. The former had a significantly higher BMI value and serum albumin concentrations in comparison to the malnourished patients. There was also a considerable difference in the mean value of C-reactive protein (CRP) among all groups. The rates of malnutrition defined by the SGA method showed a high negative correlation with BMI, MAMC and serum albumin, and high positive correlation with CRP. CONCLUSIONS We confirmed the SGA method to be simple to use, and to correlate strongly with other parameters of nutrition. We suggest that the CRP test be included in the assessment of nutritional status to determine the patient inflammatory status, considering the etiologic association between inflammation and malnutrition.

Clinical and epidemiologic characteristics of hemorrhagic fever with renal syndrome in patients treated at the Dr. Fran Mihaljević Clinic for Infectious Diseases in Zagreb

Abstract: AIM The aim of the study was to examine and analyze the main epidemiologic and clinical data of 94 patients with hemorrhagic fever with renal syndrome (HFRS) hospitalized at the University Hospital for Infectious Diseases in Zagreb during the HFRS outbreak in Croatia in 2002. PATIENTS AND METHODS A total of 110 patients with clinical diagnosis HFRS were treated at the University Hospital for Infectious Diseases in Zagreb. In 110 of HFRS suspected patients, the clinical diagnosis was verified serologically in 94 patients and they were included in the retrospective study. In 93 patients the diagnosis was confirmed by enzyme-linked immunosorbent assay (ELISA), and in one patient by indirect immunofluorescence assay (IFA). Results were analyzed by the use of descriptive statistics. RESULTS Puumala (PUU) virus infection was verified in 80 (85.1%), Dobrava (DOB) infection in 8 (8.5%) and cross-reactive antibodies to both PUU and DOB viruses in 5 (5.3%) HFRS patients. In one patient who was confirmed by IFA the hantavirus serotype causing HFRS could not be determined. The localities of the presumed HFRS patient exposure to hantaviruses were mostly in the Zagreb area. Most patients were aged 21-50 (83.0%) and male (76.6%). The majority of HFRS cases occurred between May and August (75.5%). A high proportion of HFRS cases were found in the general population from Zagreb and its surroundings (78.7%). The majority of patients were hospitalized in the febrile stage of the disease (70.2%). The main symptoms were: fever (100%), headache (88.3%) and backache (87.2%). Oliguria was recorded in 56.4% and, anuria in 7.5% of patients, however, only three (3.2%) patients required hemodialysis. Six patients developed hemorrhagic manifestations, especially petechiae on the skin and mucosa. One patient in the convalescent stage had subarachnoidal bleeding. Six patients had pathologic electroencephalogram (EEG) findings and two developed epileptic seizures. Lumbar puncture was performed in 12 patients without inflammatory changes in the cerebrospinal fluid. Pathologic ECG findings were recorded in 30/79 (38.0%) patients, primarily including mild and translent disturbances such as sinus tachycardia, sinus bradycardia, nonspecific alteration of the final complex and incomplete right bundle branch block. Conventional chest radiography revealed abnormal findings in 23/84 (27.4%) patients. The abnormalities consisted of interstitial infiltrates and/or pleural effusions and atelectasis. The patients were divided into 4 groups according to the disease severity: mild in 74 (78.7%), moderate in 15 (16.0%), severe in 4 (4.2%), and very severe in one (1.1%) patient. The latter developed multiorgan failure and died. CONCLUSION The largest outbreak of HFRS to date was recorded in Croatia in 2002. Ninety-four patients with clinical and serologically verified HFRS were treated at the Dr. Fran Mihaljevic University Hospital for Infectious Disease, Zagreb. The majority of patients were hospitalized between May and August. Most patients had mild form of the disease primarily caused by PUU virus.

[MHC tetramers: tracking specific immunity].

Abstract: In an adaptive immune response, antigen is recognized by two distinct sets of highly variable receptor molecules: (1) immunoglobulins, that serve as antigen receptors on B cells and (2) the antigen-specific receptors on T cells. T cells play important role in the control of infection and in the development of protective immunity. These cells can also mediate anti-tumor effects and, in case of autoimmune syndromes, contribute to the development and pathology of disease. The specificity of T cells is determined by T cell receptors (TCR). Understanding of the success of immune responses requires the direct measurement of antigen-specific T lymphocytes. Cell with major histocompatibility complex (MHC) class I molecules are able to present antigens to antigen-specific CD8+ cytotoxic T lymphocytes. MHC class I molecules present small peptides (epitopes) processed from intracellular antigens such as viruses and intracellular bacteria. MHC class I molecules in humans are designated as human leukocyte antigen (HLA) class I and divided into HLA-A, -B and -C. CD8+ T cells recognize MHC class I molecules and after activation produce proteins that destroy infected cells. MHC class II molecules receive their peptides mainly from extracellular and soluble antigens and present them to the CD4+ T helper cells. A recently described technique that can be used in flow cytometry enables us to quantify ex vivo antigen-specific T cells by binding of soluble tetramer MHC-peptide complexes attached to fluorochrome. Quantitative analyses of antigen-specific T cell populations provide important information on the natural course of immune responses. The interaction of T cell receptors on T lymphocytes with tetrameric MHC-peptide complexes mimics the situation on the cell surface, and allows for reliable binding. Tetramers consist of four biotinylated HLA-peptide epitope complexes bound to streptavidin conjugated with fluorescent dye. Tetramer technology has sensitivity of detection as little as 0.02% of total cytotoxic T cell pool or T helper cell pool (i.e. approximately 1 in 50.000 lymphocytes). The combination of this technology with intracellular cytokine staining methods opens up significantly better ways of studying these cells than previously possible, allowing immunologists to look at their life cycle (activation and proliferation), manner of death (aging and apoptosis) and effector function (cytotoxic potential and cytokine production). MHC tetramers class I have yielded useful insights into in vivo dynamic and function of antigen-specific CD8+ T cells in viral infections, parasitic infections, cancer, autoimmune disease and transplantation. This knowledge is of special interest for immunotherapy, diagnostic monitoring of T cell mediated immunity, and the development of new vaccination strategies. There is some possibility for cell therapy with antigen-specific CD8+ T cells for various diseases including cancer and viral infections. Targeted immunotherapy of selective deletion of auto--or alloreactive T cells with MHC tetramers may be important for the treatment of autoimmune disease, or to prevent the rejection of transplanted organs. The utility of this technique for the immunotherapy in vivo needs to be confirmed and modified in further research. Understanding how antigen-specific cells develop and function in different circumstances and pathologies will be the key to unravelling the secrets of cellular immune system.

[The value of Tc99m-DMSA renal scintigraphy in evaluation of severity of parenchymal lesions in children with acute urinary tract infection].

Abstract: INTRODUCTION Most authors would agree that renal parenchymal defects (scars, hypoplasia, dysplasia) in children are a major risk factor for chronic renal failure, and for development of systemic hypertension in later years. The pathophysiologic changes in acute pyelonephritis include tubulointerstitial inflammation/pus with impairment of the renal microcirculation due to compression of the glomeruli, small peritubular capillaries and vasa recta by interstitial edema. The resulting ischemia has been postulated as one of the mechanisms for the decreased accumulation of DMSA in the areas of pyelonephritis. DMSA scanning has a sensitivity of up to 99%, and specificity of up to 91% for the detection of acute pyelonephritis. AIM OF THE STUDY The aim of the study was to investigate the value of Tc99m-DMSA scan in children with acute urinary tract infection, to estimate the degree of parenchymal changes, and to assess the relationship with vesicoureteral reflux. PATIENTS We reviewed 116 infants aged 0-15 years, 100 (86.2%) female and 16 (13.8%) male, who were hospitalized for urinary tract infection during a 5-year period (1996-2000). The mean age at diagnosis was 3.7 years. RESULTS Escherichia colli was isolated in 52 (44.8%) urine cultures. All patients underwent ultrasonography, which was normal in 57 (49.1%) infants. Tc99m-DMSA was performed after two weeks of therapy. The renal parenchymal pathology was defined as a focal or multifocal defect of low degree in 33 (28.4%), and of high degree in 35 (30%) children. Multifocal defects were mostly found in patients aged 3 years. Renal scars were detected in 41 (35.3%) infants with first urinary tract infection. CONCLUSION We recommend that ultrasound, DMSA and radionuclide cystouretherogram be routinely performed in case of first urinary tract infection in infants aged 1 year.

[Effect of automated blood volume control on the incidence of intra-dialysis hypotension].

Abstract: Introduction Hypotension is the major cause of morbidity during hemodialysis (HD), occurring in about 20% of HD patients. Hypovolemia generated from blood volume (BV) contraction dependent on the ultrafiltration rate (UFR) and on the plasma refilling rate, is a major factor in the pathogenesis of intradialytic hypotension (IDH). Hemocontrol biofeedback system (Hemocontrol, Hospal, HBS), incorporated in the bicarbonate HD, modulates BV contraction rate by adjusting the UFR and dialysate conductivity (DC) in order to obtain predetermined BV trajectories. In the present study, HBS treatment was compared with carbonate HD to assess the efficacy in lowering the hypovolemia-associated morbidity. Patients and methods The study included 7 hypotension-prone uremic patients, mean age 69.5 +/- 6.8 years, on maintenance HD for 44 +/- 30.0 months, with over 20% IDH during 1-month observation. Treatment periods of 1 month bicarbonate HD (UFR profiles, constant DC) were compared with a follow-up period of 1-month HBS treatment (monitoring of BV and automatic adjustment of UFR and DC). The number of IDH, changes in BV, UFR, and the values of systolic and diastolic blood pressure (BP) during HD and HBS were analyzed. Results The incidence of symptomatic hypotension was considerably lower in HBS (11%, 1.3 IDH/patient) than in HD (39%, 4.6 IDH/patient), p Discussion The study showed it to be possible, by means of a technique for constant and automated BV control, to reduce the IDH incidence by affecting vascular refilling. Using BV automated regulation according to a pre-established curve, the system adjusts single oscillations of plasma refilling, affecting two output variables: UFR and sodium concentration in the dialysate which determines DC. In this study we found no statistically significant differences in final BV values during the two treatments. The lower incidence of IDH during HBS could be the consequence of not only smaller BV decrease but also of a greater stability of BV during HD and of protection from abrupt BV decrease. In both treatments, BV were considerably different only for t 60 min (HBS > HD), possibly due to the characteristic UFR profiles in HBS, with initially intense UFR. DC variations could be another important reason for higher cardiovascular stability. The increased concentration of sodium in dialysate enhances vascular refilling by affecting plasma osmolarity and by stimulating watershift from intracellular into extracellular space. Interdialytic body weight gain and BP did not differ between the two treatments, possibly due to unchanged sodium balance in both treatments. Conclusion Compared to HD, HBS is effective in lowering IDH incidence. Intradialytic measurement and modeling of BV to trajectories is a useful method for lowering hypovolemia-associated morbidity in patients with dialysis cardiovascular instability.

Prevalence and incidence of hepatitis C seroconversion in patients on hemodialysis

Abstract: INTRODUCTION Patients on hemodialysis belong to a high risk group of patients that are exposed to viral hepatitis. The aim of the study was to evaluate the prevalence and incidence of HCV infection seroconversion in this high risk group of patients. PATIENTS AND METHODS Patients were followed up from January 1997 until January 2002. During this five-year period, the dialysis population increased. There were 99 patients (58 m/41 f) in January 1997, 43 of them seropositive. Out of 186 patients recorded in January 2002, 44 had anti-HCV antibodies. The following parameters were recorded: sex, age, hemodialysis duration, number of blood transfusions, and hepatitis markers. HCV antibodies were determined by third--generation ELISA method (Behring). RESULTS The study included 164 patients (75 f/92 m), mean age 47.2 +/- 4.2 years, and mean hemodialysis duration 6.2 +/- 4.2 years. In January 1997, HCV antibodies were detected in 43/99 patients with a prevalence of 43.51%. During five-year follow-up, the highest prevalence of hepatitis C was 44% in 1998, with an extremely high incidence of 40% (8 patients became seropositive). In the first three years of the follow-up, the number of blood transfusions and duration of hemodialysis were the main risk factors for HCV transmission. The mean length of hemodialysis of seropositive patients was 6.92 +/- 4.23 in seropositive patients and 2.44 +/- 1.82 in seronegative patients (p < 0.001). Anti-HCV positive patients received significantly more blood transfusions (8.2 +/- 4.36) as compared to seronegative patients. Upon the introduction of preventive measures in 2000 and 2001, which included strict disinfection of monitors and working surfaces, connecting anti-HCV positive and anti-HCV negative patients to different machines, and use of erythropoietin, the incidence rate decreased, and in January 2002, it was 11% with a prevalence of 25%. CONCLUSION HCV infection is frequent among hemodialysis patients. The number of blood transfusions and duration of hemodialysis as well as sharing the same dialysis machines were the main risk factors of transmission of HCV infection. The use of erythropoietin and preventive measures, along with the use of appropriate protocols and separation of HCV positive from HCV negative patients led to a decrease in the prevalence and incidence of hepatitis C in our hemodialysis population.

What is new in the epidemiologic characteristics of hemorrhagic fever with renal syndrome in Croatia

Abstract: AIM The aim was to describe epidemiologic characteristics of hemorrhagic fever with renal syndrome in Croatia. METHODS We analyzed published data from obligatory infectious disease reports and notification of deaths due to infectious diseases, data on the hemorrhagic fever with renal syndrome epidemics in Croatia, and our own data. RESULTS AND DISCUSSION During the 1987-2002 period, 555 cases of hemorrhagic fever with renal syndrome were recorded in Croatia, 160 (28.8%) of them in soldiers. The mortality rate was up to 15.4% (mean 1.1%) (6/555). The highest number of cases (317) were recorded during 2002. The epidemic started in winter. The highest number of cases were recorded in June and July, i.e., during the warm season characterized by an increased activity of both animals acting as infection reservoirs and humans as hosts. The epidemic spread almost throughout Croatia. The known natural foci of hemorrhagic fever with renal syndrome are Plitvice and Slunj areas, Dinara mountain, Velika and Mala Kapela mountains, Zagreb area (Velika Gorica and Jastrebarsko), Gorski kotar area (Ogulin, Delnice), west Slavonia, and Novska area. The disease has not been recorded in the littoral area and on Adriatic Islands. The disease was also recorded in the neighboring countries of Slovenia, Bosnia and Herzegovina, Serbia and Montenegro. The identified causative agents include Dobrava and Puumala viruses of the genus Hantavirus, whereas the rodents Clethrionomys glareolus, Apodemus flavicollis, Apodemus agrarius and Apodemus sylvaticus serve as the main reservoirs of the infection in Croatia. Typical biotopes of the infection in Croatia are deciduous woods. CONCLUSION The 2002 epidemic confirms the presumption that almost all continental part of Croatia contains natural foci of hemorrhagic fever with renal syndrome.

Ocular changes in hemorrhagic fever with renal syndrome

Abstract: Hemorrhagic fever with renal syndrome (HFRS) is a rodent-originating zoonotic disease caused by Puumala and Dobrava viruses, which belong to the genus Hantavirus. The most prominent ocular change in HFRS is transient myopia, which lasts for up to one week and is due to a forward movement of the ocular anterior diaphragm and thickening of the lens. Other ophthalmic manifestations of HFRS are eyelid edema, conjunctival injection with or without hemorrhages, chemosis, anterior uveitis, retinal edema with or without hemorrhages, and photophobia. Acute glaucoma attacks, which are rare, could be explained by the increased intraocular pressure (IOP) due to edema and hemorrhage in the ciliary body, causing anterolateral rotation, relaxation of the zonules, and anterior movement of the lens. They are treated with mydriatic-cycloplegic and corticosteroid eye drops and with furosemide. However, there are also controversial reports on decreased IOP during the acute phase of HFRS. Despite the fact that ocular symptoms in HFRS are common generally they do not require any medical therapy and the recovery of the patients is complete.

Indications for continuous renal function replacement therapy

Abstract: One of the most important achievements in the contemporary intensive care management is introduction of continuous renal replacement therapy (CRRT). The most common indications for CRRT are acute renal failure complicated with heart failure, volume overload, hypercatabolism, acute or chronic liver failure, and/or brain swelling. Less common indications include systemic inflammatory response (SIRS), sepsis, multiorgan failure (MOF), adult respiratory distress syndrome, crush syndrome, tumor lysis syndrome, lactacidosis, and chronic heart failure. Methods of CRRT could be used during or after open heart operations, heart, lung or/and liver transplantation in adults and children. Modern approach to treatment of acute renal failure introduces dialysis early in the course of disease in order to avoid complications on other organs. Sepsis, SIRS and septic shock are still major therapeutic problems in intensive care units with a mortality rate over 50%. Numerous uncontrolled and several controlled clinical studies have demonstrated that CRRT could remove inflammatory substances including cytokines, activated components of the complement, and derivatives of the arachidonic acid. Hemodynamic stability and gas exchange in the lungs were significantly improved. These is due not only to removal of inflammatory substances but also to other nonspecific hemodynamic effects (control of body temperature, fluid and metabolic balance). Besides the convection, cytokines could be removed from the plasma with adsorption on the membrane of dialyzer or hemofilter. Prophylactic use of CCRT in patients with normal renal function, without disturbances in fluid excretion and with normal hemodynamics is still controversial, while the possible benefit is not higher than the risks of invasive therapeutic method, and there is no evidence that prophylactic CCRT could prevent development of acute renal failure in these patients. However, current knowledge of MOF pathophysiology justifies the use of CRRT in patients with signs of heart failure, disturbances in metabolic and fluid homeostasis and sepsis, and in patients with the risk of developing acute respiratory failure or MOF, despite the mild impairment of renal function according to laboratory results.

[An abortive type of tick-borne meningoencephalitis].

Abstract: OBJECTIVE Tick-borne encephalitis (TBE) was detected in the Koprivnica-Krizevci County 50 years ago. To date, it has retained the leading position among inflammatory diseases of the central nervous system (CNS), with an average morbidity of 20 patients per year. In 88% of patients, the infection manifested with signs of meningitis or biphasic meningoencephalitis (ME). Monophasic course was recorded in only 12% of patients of older age, during which the first initial stage remained inapparent, and the disease manifested only with ME stage. An abortive type of TBE virus infection with fever, headache and other general symptoms of infection is presented. The initial stage of the disease, without subsequent CNS involvement, is rarely described. PURPOSE OF WORK To determine the frequency and present epidemiological, clinical and laboratory characteristics as well as diagnostic procedures in patients suffering from abortive type of TBE. PATIENTS AND METHODS A prospective study was conducted in the period from 1997-2002, and included patients with possible tick-borne disease, examined at the Infectious Disease Department of the Koprivnica General Hospital. According to the set criteria, the study included patients of all age groups, sex and occupation, patients with febrile disease (T 38 degrees C) that developed within 6 weeks from the tick bite, patients who showed no signs of ME on their first examination, and patients in whom serologic analysis revealed recent infection with TBE virus. On admission to the hospital, detailed epidemiological and history data were collected, and clinical examination and laboratory testing were performed. ELISA test was used to detect specific IgM and IgG antibodies. At the same time all serum samples were tested for other tick-borne diseases, including Lyme disease and human monocyte and granulocyte ehrlichiosis. Oral consent was obtained from all patients enrolled in the study. RESULTS A total of 127 patients met the study criteria. Specific antibodies to TBE virus were detected in 49 (38.5%) patients. After the latency period, 43 (87.7%) patients developed the second stage of ME disease. An abortive type of infection with TBE virus, without subsequent CNS involvement, was recorded in 6 (12.2%) patients. The diagnosis was confirmed in the first initial stage in 12% of patients and during the second ME stage in the remaining 37 (75.5%) patients. Active immunization against TBE was not conducted in any patient. CONCLUSION We report on the first patients diagnosed with an abortive type of TBE virus infection in the Koprivnica-Krizevci County. The frequency of and new knowledge about this type of disease were assessed in the study.

Detection of human papillomaviruses and other agents causing sexually transmitted diseases with molecular diagnosis methods

Abstract: Causative agents of sexually transmitted diseases (STD) are different types of bacteria, viruses, fungi and protozoa. The last two decades of the twentieth century were marked with a sudden rise in the number of cases of STDs. Human immunodeficiency virus (HIV), which emerged in the 1980s, is the most prominent STD agent because of its fast spread and severity of the disease it causes, acquired immunodeficiency syndrome (AIDS). Beside HIV, human papillomaviruses (HPVs), herpes simplex viruses (HSVs) and Chlamydia trachomatis are nowadays among most health-threatening STD pathogens. In order to stop the spread of infection, apart from education about precautions, early detection of the disease is essential. Although most STD pathogens can be detected by classical methods of cultivation, biochemical and/or serologic methods, molecular diagnosis of infectious diseases has largely simplified and accelerated their detection. For instance, HPVs that cause benign and malignant tumors of genital skin and mucosa cannot be routinely detected on cell culture, whereas serologic analysis is not sensitive and informative enough. Moreover, cytologic (Pap smear) and histologic analyses can indicate changes associated with HPV infection, but neither of these methods can prove the presence of HPV. That is why the molecular methods are essential to demonstrate the presence of the infection and, even more important, to determine the type of the virus, which is associated either with low-grade or high-grade genital lesions. There are numerous methods based on hybridization with DNA or RNA probes, some of them are suitable for detecting wide range of types and screening of large collection of samples. However, the most sensitive and informative methods are based on polymerase chain reaction (PCR), and they have the advantage of being able to determine the type of the virus and distinguishing between multiple infections. Herein, we present when and why molecular analysis is useful and necessary for the detection of STD agents.

Clinical picture of hemorrhagic fever with renal syndrome in Croatia

Abstract: Among many viral hemorrhagic fevers, only hemorrhagic fever with renal syndrome (HFRS) occurs in Croatia. HFRS is a natural focus zoonosis with sudden onset, characterized by high fever and other clinical symptoms, renal insufficiency and hemorrhages. In Croatia, HFRS is caused by two types of hantaviruses--Puumala (PUU) and Dobrava (DOB). The basic pathologic and patophysiologic disorder in HFRS is capillary damage (vasculitis). Incubation of HFRS has not been precisely determined, it is most frequently around two weeks. The disease onset is usually abrupt. At the beginning, general symptoms include high fever and myalgias, especially in the lumbar region, and abdominal pain, as well as strong headaches, malaise and nausea, and often vomiting or diarrhea. In half of the patients respiratory symptoms occur. Later on, some patients may experience hypotension, oliguria and other signs of renal failure, and apart from petechial, severe hemorrhages may also occur in other organs. During typical clinical presentation of the disease, some characteristic symptoms are clearly distinguished in particular stages of the disease. Therefore, the course of HFRS is usually divided into five distinct stages (febrile, hypotensive, oliguric, polyuric and convalescent). Such a course of the disease is more commonly present in case of DOB virus than PUU virus infection. The febrile stage with sudden onset usually lasts from 3 to 7 days, when thrombocytopenia and hemoconcentration, as well as albuminuria and hematuria are almost always recorded. The hypotensive stage lasts from one to 2 days on an average and is characterized by lower blood pressure and signs of renal failure. The oliguric stage usually starts at the beginning of the second week of the disease, when extensive hemorrhage may occur and urea and creatinine reach their highest values. The oliguric stage is followed by the polyuric stage which can last for up to two weeks, and is characterized by excretion of a large quantity of urine of low specific gravity (up to 15 liters during 24 hours). The convalescence (convalescent stage) is slower, may last for several weeks or months, but usually resolves without complications. During the infection caused by PUU virus, the course of disease is usually milder with only two stages. The first one is febrile, followed by the second stage with renal symptoms, and rare and mild hemorrhagic manifestations. This type of disease is mostly encountered during epidemics. The mortality in severe cases of the disease (DOB virus) is 5% to 10%, whereas in PUU virus infection it is less than 1%.

[Clinical use of phase-contrast microscopy in the differential diagnosis of microhematuria].

Abstract: Cilj rada je evaluacija mikroskopije s faznim kontrastom u diferencijalnoj dijagnostici mikrohematurije. Napravljena je serijska analiza uzoraka urina u 526 bolesnika s asimptomatskom mikrohematurijom u razdoblju od 1993. do 2000. godine u Citoloskom laboratoriju Odjela za nefrologiju i dijalizu KBC-a Rijeka. Uzorci urina analizirani su na prisustvo eritrocita, ostalih stanica, drugih formiranih elemenata i detritusa. Eritrociti su analizirani s obzirom na velicinu i oblik, te klasificirani u dvije glavne kategorije: dizmorfne i izomorfne. Prisustvo >80% dizmorfnih eritrocita oznaceno je kao glomerulska hematurija. Predominacija (>80%) izomorfnih eritrocita oznacena je kao postglomerulska hematurija. Glomerulska hematurija pronađena je u 45% ispitanika, a postglomerulska hematurija u 34% ispitanika. U 4% ispitanika vrstu hematurije se nije moglo odrediti, a u ostalih ispitanika nije bilo dovoljno eritrocita u analiziranom uzorku za dijagnozu mikrohematurije. Ispitanici u kojih je pronađena glomerulska mikrohematurija evaluirani su drugim dijagnostickim postupcima na prisustvo glomerulske bolesti koja je potvrđena u 89% isitanika. Ispitanici u kojih je pronađena postglomerulska hematurija evaluirani su na prisustvo drugih mogucih uzroka hematurije. Dodatnom je klinickom evaluacijom u samo 5% ispitanika kasnije dokazana glomerulska bolest. Zakljucuje se da je mikroskopija s faznim kontrastom jednostavna, neinvazivna, jeftina i pouzdana metoda u dijagnostici glomerulskih bolesti.

[Caroli's disease].

Abstract: Caroli's disease is a rare condition characterized by congenital polycystic dilatation of the intrahepatic bile ducts. The most frequent clinical presentation of a simple type (Caroli's disease) is recurrent cholangitis, gallstone with pain, obstructive jaundice and episodes of pancreatitis in childhood and early adulthood. A more frequent type combined with congenital hepatic fibrosis is usually manifested with bleeding from esophageal varices consequential to portal hypertension. Treatment options, both conservative and surgical, are relatively limited and depend on the clinical presentation, localization of cysts in the liver, and stage of the disease. A 20-year-old man with Caroli's disease manifested with cholelithiasis and choledocholithiasis with recurrent pancreatitis at the age of 16 is presented. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography. Treatment with ursodeoxycholic acid was initiated and after two years of follow-up the disease is stable.

[Non-alcoholic steatohepatitis].

Abstract: Nonalcoholic steatohepatitis (NASH) is a condition characterized histologically by macrovesicular steatosis and lobular hepatitis with necrosis or ballooning degeneration and/or fibrosis--a picture resembling alcoholic hepatitis, in the absence of alcohol abuse. Most patients with NASH are asymptomatic, and the disease is detected incidentally. The most common signs of NASH are hepatomegaly and laboratory abnormalities, which include a 2-4-fold elevation of serum aminotransferase levels, while other liver function test results are usually normal. Most patients with NASH are obese, many have diabetes mellitus, hypercholesterolemia, or hypertriglyceridemia. NASH has also been associated with a number of metabolic derrangements, conditions, surgical procedures, and drug treatments. The pathogenesis of NASH is poorly understood, but lipid peroxidation and oxidative stress seem to be the leading culprits. The natural history of NASH is unknown, but it seems to be a stable disease in most patients. Still, the progress to cirrhosis is possible. There is no established treatment for NASH. Treatment is usually directed towards optimizing body weight, and pharmacologic agents are mostly experimentally used. Orthotopic liver transplantation is the treatment of choice for end-stage liver disease secondary to NASH.

Small rodents in the forest ecosystem as infectious disease reservoirs

Abstract: Due to numerousness of populations and width of ecologic valence, small rodents are important parts of almost any forest ecosystem. The represent an important animal group, which connects primary makers with higher trophic levels. They transmit various infectious diseases dangerous for the health of people and domestic and wild animals (trichinosis, leptospirosis, tick encephalitis, Lyme disease, hemorrhagic fever with renal syndrome, etc.). The following species of small rodents live in forest ecosystems of Croatia: Chletrionomys glareolus Schreib., Arvicola terrestris L, M. subterraneus de Sel., M. arvalis Pall., M. agrestis L, M. multiplex Fat., Apodemus agrarius Pall., A. sylvaticus L. and A. flavicollis Melch. Small rodents transmit causative agents of diseases in active (excretion products) of passive (ectoparasites and endoparasites) ways. Their multiplication potential is quite high. Transmission of certain disease sometimes takes place extremely fast due to the high number of rodents, their high movability and distribution, and the fact that they easily get in touch with men and domestic and wild animals. The number of population of each species is directly influenced by abiotic and biotic factors and changes during one year and in a several year period. In a year when the influence of ecologic factors is favorable, it is presumed that the number of these rodents will significantly increase, by which the danger of their damaging effect also increases. The following factors influence the increase of a small rodent population: number and physiologic condition of the population, meteorologic conditions, habitat, food sources, natural enemies, and diseases. The occurrence of an epidemic is closely connected to the number and infectivity of causative agents. Regular control of the number of rodent population and their infectivity can help in planning preventive epidemiologic and sanitary measures to preclude the occurrence of epidemics and individual cases of disease among animals and humans who come in contact with forest (forest workers, holiday makers, hikers, soldiers, tourists, etc.).

[Non-Hodgkin's lymphoma: clinical symptoms, therapy and prognosis in 37 patients].

Abstract: Clinical characteristics and prognostic factors in 37 patients with the diagnosis of non-Hodgkin's lymphoma made during the 1980-1998 period were retrospectively analyzed. Median age was 70 years, and 70% of patients were aged > 60. The disease was classified according to REAL classification. Twenty-seven (73%) patients had B cell lymphoma, and 10 (27%) patients had T cell lymphoma. Indolent lymphoma was diagnosed in 14, and aggressive lymphoma in 23 patients. Performance status as assessed according to the Eastern Cooperative Oncology Group scale was 0 or 1 in 73%, and worse in 27% of patients. The presence of B symptoms was recorded in 49% of patients. Lymph nodes exceeding 5 cm in size were found in 35% of patients. Erythrocyte sedimentation rate > 40 mm/h was recorded in 43%, and hemoglobin values < 125 mg/L in 73% of patients. Leukocytes were within the normal limits, i.e. below 10 x 10(9)/L, in 81%, whereas lymphocytes were within the normal limits in 86% of patients. Thrombocytopenia was recorded in 24%, and bone marrow infiltration at the time of diagnosis in 65% of patients. Complete or partial response rate was achieved by first-line therapy in 73% of patients, whereas 27% of patients failed to respond or their condition worsened. Median of the expected survival was 60 months for indolent lymphomas and 29 months for aggressive non-Hodgkin's lymphoma. Statistically relevant parameters for complete response in univariate analyses are performance status of the patient, International Prognostic Index and platelet count. In multivariate analysis, the only statistically independent prognostic factor is serum lactate dehydrogenase concentration (p = 0.037). The study confirmed the prognostic relevance of the parameters of the patient general condition according to the World Health Organization scale, International Prognostic Index and platelet count for complete response in univariate analyses. The only independent prognostic factor for the survival was serum lactate dehydrogenase concentration. The prognostic value of the International Prognostic Index was also confirmed.

pp65 antigenemia in evaluation of cytomegalovirus infection after kidney transplantation

Abstract: Introduction Cytomegalovirus (CMV) infection is the most common infectious complication after organ transplantation. Serology is useful only for detecting previous CMV infection. Dissatisfied with serologic follow-up after kidney transplantation, three years ago we introduced detection of CMV antigenemia by an immunocytochemical method using a monoclonal antibody specific for the pp65 CMV matrix protein. This test allows for quantification of positive leukocytes. The purpose of this paper is to present our three-year experience. Patients and methods From May 1999 till May 2002 CMV antigenemia was examined in 76 patients: 55 patients submitted to kidney transplantation during the study period, and 21 patients previously. Antigenemia became positive at 25.68 +/- 15.51 days after transplantation. These 76 patients were divided into three groups according to the number of positive cells per 200,000 leukocytes: 20 (group III). The groups consisted of 23, 20 and 11 patients, respectively. The percentage of patients treated by ganciclovir was 4.34%, 15% and 100%, respectively. In group I only one patient received ganciclovir because of geographic indication, in group II three patients because of septicemia, thrombopenia and leukopenia and previous miliary tuberculosis. Results One patient from group III with steroid diabetes died from pneumonia with abscess formation three days from admission. In another two patients, interstitial pneumonia and abscess of the arm developed. Five patients had an acute rejection episode each and were treated by high doses of methylprednisolone. Five patients had elevated temperature, transaminases were elevated in five patients, and neutropenia with or without thrombopenia was found in six patients. One patient had recurrent CMV disease and lymphocele. Two patients had preemptive treatment by ganciclovir based on positive CMV antigenemia. Discussion Various centers differ according to the approach to treatment of CMV infection, ranging from prophylaxis to deferred treatment for CMV disease. Determination of pp65 CMV antigenemia allowed us a safe follow-up of patients after kidney transplantation. Compared with previous serologic follow-up antigenemia is a considerable progress. We did not use CMV prophylaxis because it is more expensive and can cause resistance to ganciclovir. A promising novel drug valganciclovir will allow for good prophylaxis owing to its better absorption from the gut. Based on our three-year experience, optimal cut-off for antigenemia has been set at 20 positive cells per 200,000 leukocytes. The existence of symptoms or changes in the level of leukocytes, platelets or transaminases goes in favor of treatment decision. Conclusion Cytomegalovirus pp65 antigenemia is a reliable tool in the follow-up of patients after kidney transplantation. Patients with primary CMV infection, those with rejection episode and threshold of 20 positive cells require preemptive treatment with ganciclovir. The measurement of pp65 CMV antigenemia has clinical, analytical and cost-effective advantages. Intensive monitoring for CMV infection allows for quick and specific detection of active CMV infection. This approach avoids resistance to ganciclovir. The method is simple and specific without expensive equipment. Avoidance of unnecessary prophylaxis adds to its cost-effectiveness.

Rare renal anomalies in childhood

Abstract: Three patients with megacalycosis, a rare ren anomaly which includes dilatation of all ren calices, are presented. The symptoms of acute uroinfection were present in all three patients. The patients underwent clinical observation, laboratory testing, and renal ultrasound. Ultrasound revealed unilateral hydronephrosis in all three patients. Additional examinations included static and dynamic renal scintigraphy, voiding cystourethrography, and intravenous urography which pointed to unilateral megacalycosis. The symptoms of acute uroinfection were probably triggered by urinary stasis in dilated calices. Surgical intervention is not indicated in megacalycosis. The increasing incidence of uroinfection, urolithiasis and hematuria imposed the need of continuous follow-up in these patients.