Two trichinellosis outbreaks in Serbia - challenging diagnosis due to a potential co-infection with Toxocara spp.

In Serbia, in most cases, small family outbreaks of trichinellosis occur due to the consumption of untested infected meat from domestic pigs that are raised and slaughtered in the backyards of small individual farms. The aim of this study is to present data regarding 24 patients involved in two outbreaks that occurred in two neighbouring districts in Serbia during a closely related period of time in August 2014. The source of infection in the first outbreak was undercooked pork, while raw pork sausages caused the second outbreak. Meat samples and sausages were Trichinella spp. positive by artificial digestion. With the aim to obtain a second opinion and validate the serological findings discovered at the Public Health Institute Nis, all samples were sent to the National Reference Laboratory for Trichinellosis, INEP. Serodiagnosis showed that 21 persons were positive (87.5%) and three (12.5%) were negative for anti-Trichinella antibodies, while 15 patients fulfilled the trichinellosis case definition. Western blot analysis (using an epitope unique for the muscle larvae stage of the Trichinella genus) confirmed the diagnosis of trichinellosis in five patients. Six patients also had specific antibodies against Toxocara canis (T. canis). Due to the fact that in endemic foci in Serbia there is the presence of Trichinella spiralis and T. canis and that these two infections could be asymptomatic, we consider that trichinellosis cases were irrefutably proven. The dilemma about the existence of co-infection with T. canis remained open due to the lack of clinical findings.

Efficacy of an aerosol-resistant pepsin powder used in artificial digestion for the detection of Trichinella larvae in meat.

Trichinellosis is an important worldwide foodborne zoonosis. The gold standard test to detect Trichinella spp. larvae in muscle samples of animals intended for human consumption is the artificial digestion method. Handling and dispensing of conventional pepsin powder present significant safety risks for analysts. The use of pepsin powder that is resistant to aerosolization should alleviate these safety concerns. The aim of this study was to compare the efficacy of an aerosol-resistant pepsin powder to conventional pepsin powder in the artificial digestion method. Proficiency samples of pork diaphragm containing specific numbers of viable Trichinella spiralis larvae were tested in two laboratories. The results revealed that aerosol-resistant pepsin was simple, effective and convenient to use, and showed good solubility and larval recovery that met the requirements of the European Union regulation EU 2015/1375. Overall, the efficacy of the aerosol-resistant pepsin was comparable to the conventional pepsin and safer for analysts.

Long lasting immunity in trichinellosis - insight from a small study group.

Trichinellosis in humans is most often caused by the parasite Trichinella spiralis. The clinical course of the disease is diverse and the symptoms can vary from mild to severe. Symptoms usually disappear within a few months, but encysted larvae in the muscles can cause myalgia and weakness that last for years. However, the existence of chronic trichinellosis as a disease is still debatable. This study presents the results obtained at the National Reference Laboratory for Trichinellosis - INEP, Serbia. The study was conducted to assess the immunoserological, biochemical and symptomatic disease parameters of twelve patients who acquired trichinellosis 13 and 18 years ago, respectively. They were involved in two T. spiralis outbreaks in Serbia, at the village of Kumane and the city of Belgrade (nine and three patients, respectively). Results indicated the presence of specific anti-Trichinella antibodies in 83% of the total number of patients. However, while the humoral immune response to Trichinella lasted for more than a decade reaching almost two decades after the acute infection phase (7/9 and 3/3 respectively, in two outbreaks), persistence of chronic muscular pain, as the most prolonged symptom of trichinellosis, could be found in the majority of patients from the Kumane outbreak (7/9). As a consequence, these patients suffered from limitations in daily living activities for the same period of time. The results presented in this paper are our contribution to the view that trichinellosis as a chronic disease with symptoms exists and may be related to the severity of the disease in the acute phase.

Trichinella britovi outbreak: Epidemiological, clinical, and biological features.

OBJECTIVES: We aimed to describe the first cases of human trichinellosis due to Trichinella britovi in Serbia. A large trichinellosis outbreak due to the consumption of wild boar meat products took place during the 2015-2016 winter. PATIENTS AND METHODS: In January 2016, the Department of Infectious Diseases in Uzice examined 111 individuals with clinical and biological signs of trichinellosis, of whom 19 were hospitalized. Trichinella species identification was performed by multiplex PCR. Serodiagnosis was performed using immunofluorescence antibody assay, indirect ELISA, and Western Blot as confirmatory tests. RESULTS: The main symptoms included myalgia (83%), weakness (82%), joint pain (80%), fever (77%), facial edema (74%), and diarrhea (23%). Eosinophil levels>500/µl were observed in 98% of patients. Elevated CPK levels were detected in 71% of patients and elevated LDH levels in 75%. Three patients had cardiac complications. Treatment included mebendazole, nonsteroidal anti-inflammatory drugs, and corticosteroids. Anti-Trichinella antibodies were observed in 89.7% of patients two months after disease onset, including all hospital-treated patients. Among them, serum positivity detected one year later was 100%. CONCLUSIONS: This outbreak highlighted communication failures, from hunters to consumers. Awareness should be raised on the relation between trichinellosis and game meat. Trichinella species detection is important for adequate outbreak recording and could contribute to better understanding the clinical and serological signs of T. britovi infection.

[Hereditary angioedema in organs of the head and neck as an indication for emergency tracheotomy]. / Hereditarni angioedem organa glave i vrata kao indikacija za urgentnu traheotomiju.

INTRODUCTION: Angioedema (angioneurotic edema) is often associated with urticaria, but edema is located deeper in the skin and mucous membranes. There are limited, painless, soft and medium hard swellings. Lack of general symptoms is evident, except if mucous membranes of the gastrointestinal system are affected and pain appears. It is particularly dangerous if located in the brain or larynx when there is a risk of suffocation. In 20% cases with laryngeal involvement intubation or tracheotomy is necessary. CASE REPORT: This is a case report of a patient hospitalized at the Clinic, having a swelling at the front side of neck, lower lip and difficulties with deglutition. Occasionally the patient had similar difficulties in the main joints whereas periodical swellings are characteristic for his father, sister, and sister's daughter. Clinical check-up indicated a greyish swelling, of the oropharynx structure, with 1 cm respiratory space. Larynx was not visible due to swelling of epiglottis. The patient received intravenous steroid therapy, followed by infusion of physiologic solution with calcium. As his condition become very bad half an hour after admittance he was transported to the operation room. He received adrenaline but within the excepted time his respiration did not improve. Emergency tracheotomy was performed and afterwards his respiration and skin colour became normal. Regarding family anamnesis, clinical picture and laboratory results, hereditary angioedema was diagnosed. DISCUSSION: Hereditary angioedema is a rare form of angioedema which is an inherited autosomal dominant disorder. The disease is a result of deficit in C esterase inhibitor, which is a serum glycoprotein of SERPIN family (serum protease inhibitors), that is usually synthesized in hepatocytes. All the diseased are heterozygotes. There are two genetic variantions of the disease: I--patients with decreased quantity of inhibitor level in serum due to decreased synthesis and II--patients that have normal protein concentrations, but with abnormal protein, which is functionally inactive. Laryngeal edema can very soon cause narrowing of respiratory space, and if tracheotomy is not performed on time, suffocation occurs. Tracheotomy is one of the most urgent surgical interventions with the purpose to make patient's breathing easier to prevent suffocation and sometimes to save thr patient from certain death. CONCLUSION: In differential diagnosis of laryngeal edema, hereditary angioedema should be considered. Therapy of acute hereditary angioedema attacks should involve antihistamines, corticosteroids and adrenaline, as well as administration of fresh frozen plasma or infusion of C 1 inhibitor concentrate. Hereditary angioedema of the head and neck causing airway obstruction, is an indication for emergency tracheotomy.

[Anti-U1RNP antibodies and lupus nephritis]. / Anti-U1RNP antitela i lupusni nefritis.

INTRODUCTION: Systemic Lupus Erythematosus is characterized by production of numerous autoantibodies as an abnormal immune response. The most important antibodies are those aimed at constitutive elements of cell nucleus. METHODS: After antigen typing of antinuclear antibodies in 30 patients with Systemic Lupus Erythematosus we analyzed the correlation between anti-Sm antibodies and anti-U1RNP antibodies and the degree of disease activity, such as correlation of these two antibodies with some clinical manifestations of this disease. This study included patients who fulfilled all revised American Rheumatism Association criteria to diagnose systemic lupus. To determine the degree of disease activity we used Systemic Lupus Erythematosus Disease Activity Index after Bombardier. To detect antinuclear antibodies technique of indirect immunofluorescence and ELISA procedure for antigen typing of these antibodies were used. RESULTS: We registered antinuclear antibodies (ANA) in 100% of our patients, with domination of homogenous pattern of immunofluorescence (70%). Speakled pattern was registered in 16.66% and margin type in 6.66%. Using ELISA procedure of antigen typing of ANA we registered anti-U1RNP antibodies in 26.7% patients, while anti-Sm antibodies were registered in 20%. CONCLUSION: Anti-U1RNP antibodies finding is associated with mild forms of disease and rare appearance of lupus nephritis, while anti-Sm antibodies finding is characteristic for very active forms of disease and often lupus nephritis.

[Psoriatic arthritis: case report of acute HLA-B27 positive polyarthritis preceding the onset of typical skin changes]. / Psoriaticni artritis: povodom slucaja u kome je akutni HLA-B27 pozitivni poliartritis prethodio nastanku tipicnih koznih promena.

Psoriasis usually occurs many years before development of arthritis. This is a case report of a patient with acute polyarthritis affecting both peripheral joints and the left sacroiliac joint, preceding the appearance of typical skin manifestations for almost two months. A 44-year-old male mechanic was admitted to our institution for acute additive polyarthritis. Inflammatory synovitis primarily affected large peripheral joints (knees, ankles) in an asymmetrical pattern, with a concomitant development of unilateral sacroiliitis and later with asymmetrical involvement of several proximal and distal interphalangeal joints of the hands and feet. There were also signs of enthesopathy of the right heel. Arthritis was not proceeded by infection of the lower genital or gastrointestinal tract or serological and bacteriological evidences of streptococcal or HIV infection. Laboratory findings showed an erythrocyte sedimentation rate (92 in the first hour), positive histocompatibility antigen HLA-B27 and an increased level of acute phase reactants. Almost two months after affecting the locomotor system a typical psoriatic rash developed, first affecting the scalp and then spreading over the trunk and extremities. It was accompanied by severe onychodystrophy. The patient underwent intensive treatment with methylprednisolone (1.5 mg/kg) and cyclosporine A with significant results.

[Systemic diseases: evaluation of important laboratory parameters in 3 cases with unusual skin changes]. / Sistemske bolesti: procena znacaja laboratorijskih parametara povodom tri slucaja s neuobicajenim koznim promenama.

A whole spectrum of various clinical and laboratory disorders in patients with skin changes, may present systemic disease manifestations. Serological parameters correlate with the progression of the disease. Authors present cases with unusual skin lesions and abnormal laboratory findings, that were presumed to be manifestations of the systemic disease progression. The first case is a report of a patient age 44, female with dermatomyositis that started suddenly from full health with generalized linear bluish dark erythematous lesion like excoriations, periocular heliotrope violaceous to dusky erythematous rash with edema in a symmetrical distribution involving periorbital skin with no pruritus, diagnosed on admission as the case of acute urticarica. In the second report, a 17-year old female was referred to us because of a spread up linear sclerodermia followed by high immunological disturbances. Our third case was a 21-year old female with a systemic lupus erythematous--Rowell syndrome, with skin lesions of erythema multiforme type with some similarities to dermatitis herpetiformis on the first examination.

[Systemic necrotizing vasculitis: case report]. / Sistemski nekrotizirajuci vaskulitis: prikaz slucaja.

Systemic vasculitis presents a group of clinically pathologic syndromes with acute inflammatory process in its basis which commonly occurs on small blood vessels destroying their walls with fibrinoid necrosis. It often occurs on several organs and systems depending on the form, size and number of the diseased blood vessels. This paper is a case report on a female patient suffering from a serious systemic necrotizing vasculitis with clinically demonstrated ulceronecrotizing skin changes and purpura together with appearance of coronary ischemia; rhythmic disorders of heart rate and gastrointestinal bleeding and cardiac arrest in one moment. It contains a description of the course of the disease and a good result after application of immunosuppressive therapy with high doses of corticosteroids, cyclosporin A and plasmaphereses.

[Results of a multi-year study of persons with transplanted kidneys]. / Rezultati visegodisnjeg ispitivanja osoba s transplantisanim bubregom.

The authors review their results of five year follow up of renal transplantation. They summarised the results of treatment with three immunosuppressive regimens. There is an analysis of rejection episodes, recurrent glomerulonephritis, infections, surgical complications, a median graft as well as patient survival and other patterns of complications of renal transplantation.

[Urinary infections in patients with transplanted kidneys]. / Urinarne infekcije kod bolesnika s transplantisanim bubregom.

The aim of this study was to evaluate urinary infection frequency in kidney transplanted patients. Infection frequency was assessed in 116 patients (81 males and 35 females; mean age 36.2 years) after renal transplantation. During four year follow-up 41% patients suffered one or more episodes of infection. Bacterial infection caused by Escherichia coli were most frequent. The control group consisted of healthy medical staff and the investigations showed significantly over frequency of infection.

[Clinical and morphologic features in patients with acute nephritis syndrome]. / Klinicke i morfoloske odlike bolesnika s akutnim nefritisnim sindromom.

Acute glomerulonephritis is a distinct clinical entity, more frequently found in younger age. We report 69 patients with AcGN (25 female and 44 male) mean age 26 years (range 15-58). The disease is clinically characterized with hypertension (57%), edema (59%) and oliguria (35%). Urine analysis showed microhaematuria/proteinuria (36%) and micro/macrohaematuria alone in 89%, while azothaemia was observed in 16% pts, and decreased serum complement levels in one third of patients, more often decrease of C3 (33%) than C4 (15%). Initial infection of the upper respiratory tract was seen in 65%, pneumonia in 8%. In 25% of pts. there were no data of previous infection. Cultures of pharyngeal smear revealed. Streptococcus only in 2 pts. Elevated AST titer was found in 32% pts. Eleven kidney biopsies were made, and histological examination showed 2 normal findings, 6 mesangioproliferative GH, 2 endocapillary GN and 1 membranoproliferative GN. Follow ups have showed urinary abnormalities in 25% of pts., without developing renal failure.

[Methylprednisolone pulse therapy in the early phases of lupus nephritis]. / Dejstvo pulsne terapije metilprednozolonom kod ranih faza lupusnog nefritisa.

Renal involvement i.e. lupus nephritis (LN) in systemic lupus erythematosus (SLE) mainly determines course and outcome of the disease. Recognition of early manifestations of LN makes adequate therapy possible, with very good therapeutic results. We report 7 patients from a group of 150 SLE patients under our permanent control, 4 female and 3 male, mean age 21 years. All of them had signs of LN: proteinuria 7/7 haematuria 4/7 without azotaemia. Renal biopsy was performed in 6 pts, and histological finding was: class II 1 pt, class IV 3 pts and class V in 2 pts. In 4 pts tubulointerstitial changes were noted, while all showed immunofluorescent deposits of immunoglobulins and complement. Methylprednisolone "pulse" therapy (1000 mg, i.v., 3 days) followed by tapering of the steroid dose was given. Reduction of proteinuria and disappearance of haematuria were observed in all patients. During follow up, kidney function remained normal.

[Chronic urticaria from the aspect of autoimmune diseases]. / Hronicna urtikarija s aspekta autoimunih bolesti.

At some time in their lives one in a five persons is affected by urticaria and/or angioedema. The cause of urticaria may never be found in up to one quarter of patients with acute urticaria and in up to 90-95% with chronic urticaria. In this study we present results of our compounded approach (clinical follow up, laboratory findings, allergological testing) to patients with chronic urticaria and autoimmune diseases that progressed into chronic urticaria or started before the onset of the chronic urticaria. Our first case was a 56 year old woman with a 10 month history of chronic urticaria, angioedema and chronic gastritis before the diagnoses of insulin dependent Diabetes mellitus and Hypothyreoidismus primarius were established. Allergological testing reveals specific clinical significant immediate reaction to Balsam Peru. After adequate substitutional therapy was advocated and with specific clinical avoidance of offended allergen, remission was obtained. The second case was a 46 year old female suffering from chronic urticaria (with clinical features of urticaria like vasculitis) associated with hypocomplementemia (particularly C4 depressed) with negative antinuclear antibodies but positive circulating immune complexes after a 2 year follow up the patient developed Systemic lupus erythematosus. The third case was a 63 year old woman who developed chronic urticaria 3 years after total thyroidectomy, with pathological finding of Thyroiditis lymphocytaria-Hashimoto; after the allergological testing, positive lymphocyte transformation test revealed allergical sensitization to Vobenol was substituted with Thyvoral, complete remission was obtained.

[Hemorrhagic fever with renal syndrome in Vojvodina]. / Hemoragijska groznica s bubreznim sindromom u Vojvodini.

This paper presents 4 serologically confirmed cases of hemorrhagic fever with kidney syndrome. The objective of this study was to point to occurrence of unexpected hemorrhagic fever with kidney syndrome, to different clinical pictures and differential-diagnostic difficulties as well as to therapeutic procedures of serious cases. The disease had a sudden onset with general signs of infection in all our patients. 3 out of 4 patients had had a dominant symptomatology in regard to gastrointestinal tract, whereas signs of acute renal insufficiency appeared later. In 3 patients there was a complete recovery without consequences, while one female patient died on the twelfth day of the disease.

[Immunologic characterization of autoreactivity to nuclear antigens in patients with systemic lupus erythematosus]. / Imunoloska karakterizacija autoreaktivnosti prema nuklearnim antigenima u bolesnika sa sistemskim eritemskim lupusom.

Abnormal immune reactivity, with a production of multiple autoantibodies specially against the components of a nucleoplasm is one of the hallmarks of systemic lupus erythematosus (SLE). Our investigations were conducted on 102 patients with SLE, classified according to the criteria of ARA, aiming to better characterize the overall incidence of anti-nuclear antibodies in SLE, to determine the type of immunofluorescent staining of the nuclei, and to characterize the fine specificity of such antibodies using modified ELISA procedure. Results of our investigation show that 95% of patients with SLE have detectable anti-nuclear antibodies. Predominant pattern of nuclear staining is homogeneous, followed by a speckled type, while the rim (peripheral) pattern is relatively infrequent. Anti-nuclear antibodies showed the highest reactivity against native DNA (70% of patients), which was followed by binding to SS-A, eRNP and SS-B antigens. Interestingly, using ELISA procedure we could observe the reactivity against Sm antigen only in 5% of SLE patients. In patients who showed homogeneous or rim pattern of nuclear staining the predominant type of reactivity was against native DNA, while in patients with speckled type most frequent binding to non-histone proteins was observed. The most frequently observed individual pattern of ANA reactivity was of polyreactive type.

[Possibilities in the practical use of computers in the selection of candidates for kidney transplantation]. / O nekim mogucnostima prakticne primene racunara u izboru kandidata za transplantaciju bubrega.

This paper points out some problems appearing in the selection of candidates for the cadaveric kidney transplantation treats basic issues regarding medical and other references important for making decision in the process of candidate selection, emphasizes the significance of data base for prepared candidates and presents the specific example of the applications of APLLE II C in the practice of the clinic for nephrology. The data for each candidate are grouped in two sections: A. PERSONAL DATA 1. Family name and surname 2. Year of birth 3. Place of residence 4. Address 5. Telephone number 6. Register number of case history 7. Date of enlisting B. BASIC MEDICAL DATA 1. Blood type 2. HLA tipization of tissue: A, B, C, DR 3. Cytotoxic antibodies 4. Urgency priority 5. Date of eventual previous transpl. 6. Special remarks This mode of Candidate selection provides the availability of all relevant data at one place: objectivity and high efficiency. Creation of such data base in every Yugoslav Kidney Transplantation Center would "at the time" mean the formation of YU Information System, thus providing a possibility of choice of the most appropriate cadaveric Kidney recipient on Yugoslav level at any time.