Ongoing outbreak of aseptic meningitis associated with echovirus type 30 in the City of Novi Sad, Autonomous Province of Vojvodina, Serbia, June - July 2010.

Since June 2010, incidence of aseptic meningitis has increased in Novi Sad, Autonomous Province of Vojvodina, Serbia. From 2 June to 25 July 2010, 80 cases of aseptic meningitis were notified, with an incidence rate ranging from 10 to 366 per 100,000 population in different local communities. The majority of cases (n=64) were aged between two and 15 years. Echovirus 30 was cultured from two of four cerebrospinal fluid specimens. The outbreak, for which no common source has yet been identified, is ongoing.

[Clinico-epidemiologic characteristics of Lyme disease treated at the Infectious Disease in Novy Sad 1993-1998]. / Klinicko-epidemioloske karakteristike lajmske bolesti lecenih na Klinici za infektivne bolesti u Novom Sadu u periodu 1993-1998. godine.

INTRODUCTION: Borrelia burgdorferi, the etiological agent of Lyme disease, is transmitted by the bite of Ixodes ricinus, registered in all parts of Yugoslavia. Vectors are very active in spring and early summer and the disease has a seasonal distribution. Generally speaking, there are three defined stages of the disease, but some of them can be misdiagnosed or really absent. Serological analysis of Lyme disease is very difficult to interpret, especially in later stages, so confirmation by immunoblot assays is recommended. The aim of this study was to present some epidemiologic and clinical characteristics of Lyme disease in Vojvodina in the period from 1993-1998. Throughout this period, 1.659 persons with tick bite were registered, whereas 560 with diagnosed Lyme disease have been treated at the Clinic for Infectious Diseases in Novi Sad. RESULTS: In 511 patients (91.25%) we registered the first stage of the disease, in 42 (7.50%) the second stage and in 7 (1.25%) the third stage of the disease. The mean age of patients with erythema migranes was 38.67 years, mean incubation period was 9.37 days, and tick was removed from the skin after 2.29 days on average. Most of the identified tick bites originated from suburban areas (50.29%), they predominantly occurred in May and June (63.01%), and most of the ticks were removed improperly (57.67%). Dominant clinical manifestations of the second stage were acute meningitis (9.52%), Bannwarth's syndrome (9.52%), arthralgia and arthritis (50%), skin lesions (14.28%), cardiac disorders (11.90%) and mild liver lesions (2.38%) and generalized lymphadenopathy (2.38%). Chronic neuroborreliosis (42.85%), acrodermatitis chronica atrophicans (28.57%) and chronic arthritis were dominant clinical manifestations of the third stage. Up to 81.63% of patients with late stage of disease had a history of previous tick bite. One third of patients were asymptomatic in the first stage of the disease. Improper treatment of the first stage resulted in development of late stage disease in 57.14% of patients. CONCLUSIONS: Morbidity of Lyme disease in Vojvodina is about 1.98-9.8 cases on 100.000 inhabitants, and it belongs to regions with low incidence. Majority of bites are registered during summer months arround cities. Longer persistence of vector on the skin is a risk factor for manifested diseases. Inappropriately treated or completely untreated persons have higher risk for disseminated infection. In our country, most common manifestations of the second stage are neurological and articular manifestations as in the third stage. Leading symptoms and epidemiology aren't enough for diagnosis of Lyme disease, and more specific and sensitive serologic assays are necessary.

[Neurotrichinosis]. / Neurotrihineloza.

INTRODUCTION: Trichinellosis is an anthropozoonosis caused by Trichinella spiralis. Central nervous system complications can occur during the course of this disease. This paper presents a case of neurotrichinellosis, assayed by using indirect immunofluorescence test. CASE REVIEW: A patient aged 30, was admitted to the Clinic on the fifth day after onset of the disease, which was gradual, starting with flu-like symptoms. Two days before admittance, the diseased became somnolent, disconcerted and disoriented. On admission, the patient was highly febrile (39 degrees C), dehydrated, with eyelid edema. Right hemiparesis was present. The disease was confirmed by indirect immunofluorescence test, showing an increase of trichinella antibody titre (1:20, 1:160 and 1:640). The cerebrospinal fluid was cytobiochemically normal. Electroencephalographic findings exhibited a moderate cerebral dysfunction. Multifocal unspecific changes were established by magnetic tomography. The diseased was treated by mebendazole and prednisolone. The course of the disease was favourable and the patient was cured without sequelae. DISCUSSION: Recognition and diagnosis of Trichinellosis are complicated due to its polymorphid symptomatology. In the case reviewed, the disease started with clinical features of flu-like symptoms and febrile gastroenteritis. According to some authors, central nervous system manifestations occurred in 10-15% of the diseased. CONCLUSION: When examining clinically manifested encephalitis, Trichinelosis should be taken into consideration as a cause of the disease.

[Clinical and diagnostic approaches to neurocysticercosis]. / Klinicki i dijagnosticki pristup neurocisticerkozi.

ETIOLOGY: Cysticercosis is a tissue infection caused by larvae of the cestode Taenia solium. Neurocysticercosis is a central nervous system form of this infection. Taenia solium invades tissues in a form of a cyst with a thin, semitransparent wall. It can reach 1-2 cm in diameter in muscles and brain tissue and up to 3-6 cm in brain chambers. EPIDEMIOLOGY: Pigs are the most common intermediate hosts. The infection occurs when the parasite eggs or proglottids are ingested. It is most common in regions where human feces is used as a fertilizer, or regions with poor sanitary conditions. The man is infected with contaminated food or water, or by autoinoculation. PATHOGENESIS: The Taenia solium eggs are hatched in the duodenum. Embryos invade the intestinal mucosa, and reach various parts of the body, disseminated by the blood circulatory system. The most common localizations of cysticerci are skeleton, muscles and brain. While alive, these cysts produce a minimal reaction in hosts. Inflammation occurs when they die, often a few years after infection. CLINICAL FEATURES: While presence of adult worms of Taenia solium in the gastrointestinal tract causes unspecific symptoms, clinical features of neurocysticercosis depend on the number, size and localization of cysts, as well as on the degree of granulomatous response. The most common manifestations of this infection are epileptic seizures, whereas intracranial pressure increase can be the earliest sign of the disease. Hydrocephalus, meningitis and spinal cord compression syndrome are the most usual complications. PROGNOSIS: The death rate is low in neurocysticercosis with parenchymal cysts and calcification without hydrocephalus. However, fatal outcome occurs in hydrocephalic patients, cases with huge supratentorial cysts, multiple granuloma, brain edema or cerebral infarctions. DIAGNOSIS: Informations about travels to endemic regions are valuable in diagnosing neurocysticercosis. Cytobiochemical finding of the cerebrospinal fluid is often normal. However, in 50% of patients, lymphocytic or eosinophilic pleocytosis is found, low glucose (in 25%) and elevated protein (in 40% of cases). Further testing includes serologic examination of blood and cerebrospinal fluid. Finding of specific antibodies in the sera or cerebrospinal fluid confirms the diagnosis, although false positive reaction may occur in patients with other helminths, especially other cestode. The enzyme-linked immunotransfer blot assay is proven to be sensitive and specific in patients with multiple cysticerci. Computerized tomography and magnetic resonance imagining are techniques mostly used in establishing neurocysticercosis. They reveal the localization of cysticerci, identify the atrophic or edematous fields and assess the degree of ventricular dilatation.

[Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease)]. / Histiocitni nekrotizirajuci limfadenitis (Kikuchi-Fujimotova bolest).

INTRODUCTION: Histiocytic necrotizing lymphadenitis is a disease of unknown etiology, favourable course and outcome, mostly encountered in young women. It exhibits increased temperature and lymphadenopathy. The illness resolved spontaneously after a few months. A CASE REVIEW: In a 32-year-old patient the disease developed gradually, with pain in the right axilla, within enlarged lymph. Two weeks later, her temperature increased to 39 degrees C, accompanied by fever, shivering, malaise and loss of appetite. The ultrasonographic finding showed a conglomerate of hypoechogenic lymph nodes, with a few enlarged lymph glands. By immunohistochemical examination of a gland tissue sample the diagnosis was established Kikuchi-Fujimoto disease ("Histiocytica necrotizing lymphadenitis"--"Apoptotic lymphadenitis"). Corticosteroid therapy had been administered for one year, which resulted in both subjective improvement and regression of enlarged lymph nodes. DISCUSSION: A connection between this disease and viruses has not been proved. Presence of intracellular tubuloreticular formations suggests autoimmune etiology of histiocytic necrotizing lymphadenitis. It is considered as hyperimmune reaction of the organism induced by a viral infection. Differential diagnosis should consider taxoplasmosis, tuberculosis, lymphadenitis and malignant lymphoma. CONCLUSION: Although histiocytic necrotizing lymphadenitis is a rare disease, this case shows that it should be considered when lymphadenopathy, particularly cervical, occurs in young women, accompanied by increased temperature.

[Herpes simplex and lymphocytic choriomeningitis viruses in infections of the central nervous system--clinical and cerebrospinal fluid characteristics]. / Virusi herpesa simpleks i limfocitarnog horiomeningitisa u infekcijama centralnog nervnog sistema--klinicke i likvorske karakteristike.

INTRODUCTION: A great number of various viruses are stated as the cause of acute infections and damages of the central nervous system. In most cases these are minor damages which exhibit as meningeal syndrome and a specific finding in the cerebrospinal fluid. According to the dominant location, central nervous system infections can take a form of meningitis, encephalitis or myelitis. Since the inflammatory process of the meninges can not be separated from the inflammatory process of the brain, we usually speak of meningoencephalitis. The etiological diagnosis of meningitis and encephalitis is established by isolating the virus from the cerebrospinal fluid and by finding the presence of the specific antibodies in the blood and in the cerebrospinal fluid. The most common causes of the viral meningitis are Enteroviruses, the Mumps virus, Arthropode borne viruses, the Herpes viruses, Adeno viruses and the Lymphocytic choriomeningitis virus. The aim of our study was to establish the correlation between the clinical features and immunological and cerebrospinal fluid changes and the degree of the damage to the blood-brain barrier during the infections of the central nervous system, caused by the Herpes Simplex virus and the Lymphocytic choriomeningitis virus. MATERIAL AND METHODS: From a group of 103 patients, who had been treated for viral meningitis and meningoencephalitis, a group of 27 patients with established specific viral etiology--Herpes Simplex virus and Lymphocytic choriomeningitis virus, had been taken into the account. Herpes Simplex infection had been proven by the complement binding reaction and the neutralisation test of the even samples of serum. The diagnosis of Lymphocytic choriomeningitis was confirmed by the immunofluorescence test of the pharynx swabs and cerebrospinal fluid. The clinical features, such as body temperature, encephalitic signs, and electroencephalographic findings had been followed and compared. RESULTS: Herpes Simplex infection had been found in 20 patients, Lymphocytic choriomeningitis had been proven in 7 patients. All the patients had increased body temperature. Only four of the patients exhibited encephalitic signs, all infected by the Herpes Simplex virus. Patients from the Herpes Simplex group showed various degrees of consciousness disturbances, ranging from somnolence to coma, while the Lymphocytic choriomeningitis patients exhibited none. Higher pleocytosis and protein level had been found in the Lymphocytic choriomeningitis group. DISCUSSION: Viral diseases of the central nervous system are the result of the direct damage of the brain and meninges by the virus and immunological processes. Herpes Simplex meningitis usually has a good prognosis. Lymphocytic choriomeningitis has longer course of the disease and exhibits more severe clinical features. CONCLUSION: In cases of the central nervous system infections, caused by Herpes Simplex virus or Lymphocytic choriomeningitis virus, the correlation between the severeness of clinical features and the degree of damage of the blood-brain barrier, the level of pleocytosis and the increase of the cerebrospinal fluid proteins had been established.

[Therapeutic approach to neurocysticercosis]. / Terapijski pristup neurocisticerkozi.

Neurocysticercosis is a clinical form of parasitic infection caused by Taenia solium. Therapy is recommended only for the symptomatic form of illness and whether to apply conservative and/or surgical treatment, depends on the localization of the infection in the nerve tissue, the number of cysts and symptoms of the infection. Conservative therapy (drug therapy and supportive therapy) is the therapy of choice for majority of patients, while Albendazole has proved better than Praziquantel in many clinical trials. The recommended dose of Albendazole is 10-15 mg/kg/24h during 8-28 days, whereas for Praziquantel it is 50 mg/kg/24h in three divided doses during 15 days. It is considered that combined therapy of Albendazole and Dexamethasone has better effects because of increased serum concentration of Albendazole metabolites. Implantation of intraventricular shunt and/or removal of cysts are surgical procedures in management of neurocysticercosis. Combined conservative and surgical treatment is most often applied in extraparenchymal forms and those parenchymal forms of neurocysticercosis in which symptoms persist despite antihelmintic therapy, while cysts are accessible for surgical treatment.

[Bacterial meningitis with a low leukocyte count at the beginning of hospital treatment]. / Bakterijski meningitisi sa snizenim leukocitima na pocetku bolnickog lecenja.

The clinical pictures and the course of bacterial meningitides in 7 patients with leukocytes in the peripheral blood below 6.0 x 10(9)/l was examined out of 7 patients 6 were female and 1 male, from 7 months to 56 years of age, the mean age X = 22.3 years. At the beginning of the hospital treatment, patients from this group were more frequently afebrile or subfebrile (5 patients) meningitic signs significant (4 patients). Parameters of nonspecific inflammatory response in blood, SE and fibrinogenaemia were less expressed, while the response in liquor to bacterial infection was normal. Gram-negative bacteria were more frequently isolated among etiologically established causes of meningitides. In patients with leukocytes below 6.0 x 10(9)/l, purulent meningitides were more often serious and very serious diseases (4). There were no complications in some patients and 5 patients were completely cured (71.42%), while in 2 patients (28.58%) there was a mild hyperproteinorrachia in the liquor at the time of leaving hospital.

[Leptospirosis at the Clinic for Infectious Diseases in Novi Sad 1984-1993]. / Leptospiroze na Klinici za infektivne bolesti u Novom Sadu u periodu 1984-1993. godine.

We examined the clinical picture and course of leptospiral infections in 50 patients treated at the Clinic during the period 1984-1993. Most patients were 11-20 years of age (9 years the youngest and 77 years the oldest, mean age being 25.16). The disease more often occurred in male patients, 44 (88%). There were 30 (60%) patients with gastrointestinal symptoms, while 21 (42%) had liver and kidney infections. Meningeal syndrome was established in 25 (50%) and serous meningitis in 13 (26%). Leptospiral infections represented average and serious infections with complications in 8 (16%) patients, successful treatment in 47 (94%) patients while 3 (6%) patients died due to hematorenal insufficiency.

[Intrathecal synthesis of immunoglobulin G in patients of various ages with acute viral meningitis and meningoencephalitis]. / Intratekalna sinteza imunoglobulina G kod bolesnika razlicitog zivotnog doba u toku akutnih virusnih meningitisa i meningoencefalitisa.

Intrathecal antibody synthesis is a common local immunologic reaction in acute meningoencephalitis and encephalitis caused by Herpes group viruses, myxo and paramyxoviroses. The purpose of this study was to determine the quantity of de novo synthesized IgG during 24 hours in the liquor of patients of different ages suffering from acute viral meningitis and meningoencephalitis and to establish correlations between the dysfunction of blood-brain barrier and de novo IgG synthesis. We examined 73 patients of different ages divided into 5 groups according to their age. The state of blood-brain barrier was the most stable with high Qalb values of 225,596 for the youngest (from 2 to 6) and 193,190 for the somewhat older children (from 7 to 15). The most common damage of the blood-brain barrier was established in the oldest group of patients--over 40 years of age. The lowest intrathecal IgG production was established in the youngest group from 2 to 6 (6.631 mg/24 hours), and the highest (64.61 mg/24 hours) at the beginning of the disease in the group from 16 to 25 years of age. We established a correlation between damages of blood-brain barrier and de novo synthesis of IgG, especially in the youngest patients in the first days of the disease as well as 14 and more days later, when a low immunoglobulin production was established but a well preserved blood-brain barrier too. In the group of patients older than 40 years of age such a correlation was not found which points to a tissue synthesis of antibodies in the central nervous system.

[Prediction of progression of suppurative meningitis based on clinical characteristics and cerebrospinal fluid findings at the onset of the disease]. / Mogucnosti predvidanja toka gnojnih meningitisa na osnovu klinickih karakteristika i likvornog nalaza na pocetku bolesti.

Some factors (sex, age, the way of onset, previous antibiotic therapy, instant of hospitalization in relation to the appearance of initial symptoms) associated with the course of suppurative meningitis prior to the hospitalization have been analyzed and a trial has been made to locate them in the prognosis of the disease progression. At the Clinic of Infective Diseases in Novi Sad during 10 years (1977 to 1987, except 1983) 162 patients with a diagnosed purulent meningitis had been treated. The patients were classified into two groups: a group of 62 patients with complications and a group of 100 patients with an expected progression of the disease. Statistical data were analyzed using the x2 test and t test. In the period considered in this investigation the sickness passed with complications in 38.24% cases, 32.10% of them being of neurological nature, while 6.14% of complications appeared in other organs and systems. The statistical analysis shows that sex, age, the way of onset (data from history of the disease), previous antibiotic therapy, time of hospitalization in relation to appearance of initial symptoms, can not be used as reliable parameters in predicting the further course of suppurative meningitis. Complications have been registered in patients having more than 2.16g/l proteins and less than 1.12mmol/l sugar in the liquor at the beginning of the disease. These values can be used as a reference for predicting the further course of the disease.

[Sensorineural impairment in the inner ear in epidemic parotitis]. / Senzorineuralno ostecenje unutrasnjeg uva u toku epidemicnog parotitisa.

During morbilli and mumps, classical forms of acquired deafness develop in childhood. The aim of the study was to investigate effects of mumps virus on cochlear function. Of 237 examined patients 71 had parotitis and 166 meningitis-meningoencephalitis. Audiometric analyses were carried out at the beginning of the treatment and after 6 months. Hearing loss above 30 dB was found in 109 patients (45.99%). Mild hearing impairment of sensorineural type was registered in the majority of patients, while total one-sided hearing loss was found in 2.53% of subjects. No correlation between clinical manifestations of parotitis or meningoencephalitis and hearing loss was found. Cytochemical liquor levels did not influence the development of hearing loss. 6 months later a recovery followed mainly in patients with mild impairments.

[Etiologic structure and clinical characteristics of acute viral infections of the central nervous system with hyperproteinorachia]. / Etioloska struktura i klinicke karakteristike akutnih virusnih infekcija centralnog nervnog sistema sa hiperproteinorahijom.

Clinical syndrome of acute viral meningitis and meningoencephalitis may be induced by different viruses. Etiologic diagnosis may be set by the isolation of the virus from the liquor and by the detection of specific antibodies in the blood and liquor. Our aim was to determine viral etiology of AVI with special reference to hyperproteinorachia. The study was conducted in 55 patients treated at the Clinic of Infectious Diseases in Novi Sad, with clinical picture of acute meningitis or meningoencephalitis, with pleocytosis above 50 ml in the cerebrospinal fluid. Depending on the levels of proteinorachia the patients were divided into the group with proteinorachia levels below 1g/l (34 patients) and above 1 g/l (21 patients). In the first group the most common was herpes simplex- and adenoviral etiology while in the second group most frequently found were choriolymphocytic meningitis virus (LCM) and herpes simplex virus. The protein level was in correlation with the severity of the clinical features and the duration of the treatment.

[Meningococcal sepsis and difficulties in differential diagnosis--case report]. / Meningokokna sepsa i diferencijalno-dijagnosticke teskoce--prikaz slucaja.

We report a case of meningococcal sepsis in a healthy immunocompetent sixteen year old boy who had developed upper respiratory tract acute infection 10 days before the admittance. Clinical manifestations were similar to those found in allergic hemorrhagic purpura (Schonlein's form of the disease). The clinical course of these two diseases is usually different but sometimes they cannot be easily differentiated. The acute onset of polyarthritis, temperature and skin manifestations in the form of erythematous maculopapular exanthema which within several hours evolved into hemorrhagic purpura is typical for the sepsis caused by Neisseria meningitides but these characteristics might be found in allergic Henoch-Schonlein' purpura as well. In our case the accurate diagnosis was set by the identification of the group C Neisseriae meningitides from the patient's blood. The first choice was penicillin therapy.

[Typhoid fever--case report]. / Tifusna groznica--prikaz slucaja.

The paper describes a case treated at the Department of Infective Diseases in Novi Sad admitted during the remittance of typhoid fever. The course of the disease was atypical. Epidemiological and clinical features resembled those found in malaria but laboratory findings gave the true diagnosis. We found the case interesting because the diseased patient moved around a lot, making contacts with many people. Fortunately, contact diseases never happened to occur.

[Mumps infection and disorders of glucose tolerance]. / Mumps infekcija i poremecaji glikozne tolerancije.

In the last few years there is a more frequent appearance of papers which suggest the viral etiology of juvenile diabetes mellitus, where the mumps virus is primarily pointed to as the etiological factor. Since there is a high incidence of diabetes in our Province as well as the presence of an epidemic appearance of mumps infections, we were of the opinion that there was good reason for us to study the influence of mumps infection on glucose tolerance. With our research we have proved that mumps leads to the disturbances of carbohydrate metabolism and this is the case not only in the acute stage of infection but also in the course of a two-year follow-up, and they develop as a consequence of the direct influence of the virus on the beta cells of the pancreas. Glucose tolerance disturbances were not in correlation with the changes on the exocrine part of the pancreas neither in the acute stage nor in reconvalescence. Hereditary factors also didn't influence the more frequent appearance of these disturbances in persons with a hereditary disease, which was confirmed statistically also (X2 = 0.67). By research we have proved that disturbances which take the course of the "slow virus infection" type also occur and that they are statistically more significant (X2 = 22.31) in relation to the glucose tolerance disturbances which develop due to a direct activity of the mumps virus.