Severe hypocalcaemia in a COVID-19 female patient.

SUMMARY: Comorbidities are a risk factor for patients with COVID-19 and the mechanisms of disease remain unclear. The aim of this paper is to present a case report of an COVID-19 patient with severe hypocalcaemia. This is a report of an 81-year-old female, suffered from myalgia and fatigue for more than 3-4 weeks. Fever and cough appear 2 days before she presented to the emergency room. On physical examination, she was febrile with a temperature of 38.8°C, accompanied by cough, sore throat, headache, fatigue, and muscle ache. Her past medical history was remarkable with no chronic disease. She had lymphopenia. Laboratory test revealed moderate liver dysfunction, hypoalbuminemia, and severe hypocalcaemia (serum corrected calcium level: 5.7 mg/dL). Parathyroid hormone (PTH) was 107.9 pg/mL (range: 15-65) and 25(OH)2D levels was 4.5 ng/mL (range: 25-80). Chest CT scan detected peripheral ground-glass opacity. Throat swab for coronavirus by RT-PCR assay tested positive for the virus. She was treated with lopinavir/ritonavir, third generation cephalosporin, anticoagulant, daily high-dose calcium acetate, vitamin D3, fresh frozen plasma and oxygen therapy. She was discharged after two negative throat swab tests for coronavirus by conventional RT-PCR. LEARNING POINTS: Comorbidities are a risk factor for patients with COVID-19. Laboratory findings are unspecific in COVID-19 patients; laboratory abnormalities include lymphopenia, elevated of LDH, CPK and the inflammatory markers, such as C reactive protein, ferritinemia and the erythrocyte sedimentation rate. In addition to inflammatory markers, in COVID-19 patients it is crucial to check the level of vitamin D and calcium. There may be a correlation between vitamin D deficiency and the severity of COVID-19 disease.

Supporting healthcare workers on front lines of the Covid-19 fight.

Un unexpected infection by a novel coronavirus (SAR CoV-2) started by the end of December in Wuhan, China, spreading all over other countries, and Italy was one of the most affected ones. WHO declared the pandemic on 11th March, 2020. Despite the numerous unknown aspects of this infection, the healthcare system had to face a multidimensional emergency. Albania, a small country with a geographical, historical and cultural relationship with Italy was one of the first countries giving support and starting a profitable collaboration focusing on the mission to provide the necessary help for the health care workers. In order to help the Italian healthcare system to face up to the situation two medical teams firstly (in March) and a group of 60 health care workers later in April were sent to Italy (Brescia Hospital) to support clinical activities in departments with COVID-19 patients. This important contribution showed the great solidarity and helped to strengthen the partnership between the two countries.

A case with high bilirubinemia and hemolytic anemia during leptospirosis and a short review of similar cases.

BACKGROUND: Leptospirosis is characterized by very diverse clinical manifestations, which may range from flu-like subclinical forms to very severe presentations characterized by multi-organ failure, or to atypical presentations. One of its most aggressive presentations is Weil's disease, characterized by jaundice, hemorrhagic phenomena and renal failure. Cases with high bilirubinemia over 30mg/dL are not communes in human leptospirosis. Our aims are to present an atypical case presentation of human leptospirosis, characterized by jaundice and hemolytic anemia, and to make a short review in PubMed for similar cases. At the same time we want to emphasize the diversity of the clinical presentation of human leptospirosis. METHODS: A 54-year-old man presents at the emergency department of the infectious medicine with severe fatigue, nausea, vomiting, and generalized weakness. On exam, he was alert and well oriented; blood pressure was 80/50 mmHg and icteric. First blood examinations confirmed high bilirubinemia, thrombocytopenia and acute renal failure. RESULTS: Based on anamnestic and clinical evaluations, blood and serology examinations, the patient resulted with leptospirosis. The bilirubin reached 73.4mg/dL. At the same time on PubMed research we found only limited cases with leptospirosis associated with bilirubinemia over 30mg/dL and over less with hemolytic anemia. CONCLUSION: Based on our clinical experience, as well as literature data, we suggest that clinicians should have a high index of suspicion in cases of jaundice with exposure possibilities for infectious diseases. Connection of high bilirubinemi over then 30mg/dL and hemolytic anemia in human leptospirosis is an unical case report.

Two cases of imported hemorrhagic fever with renal syndrome and systematic review of literature.

Many factors are involved in the epidemiology of hemorrhagic fever with renal syndrome (HFRS). Imported cases, as well as those by emigrants, have been reported in literature worldwide. Our goal is to document two cases of HFRS, imported by two immigrants from two countries, and to make a review of the imported HFRS literature data. We performed a systematic literature review (PRISMA guidelines) of imported cases of HFRS and herein describe our two clinical cases. We found 20 published papers, with 16 of them in English and 4 in other languages. Twenty-three patients with travel- or immigration-associated HFRS, including our two cases, were identified. We included only papers that were in English. The average age of the patients was 35.9 ±â€¯15.13 years, and the ratio of male to female was 8:1. Imported disease from Europe to Europe occurred in seven cases, America to Europe occurred in four cases, Europe to America occurred in two cases, America to America occurred in two cases, Asia to Asia in one case, Asia to Europe in one case, and Europe to Asia in one case. The results of the two cited cases are based on the clinical-laboratory, anamnestic, and serologic data for both the patients who tested positive for HFRS. Our systematic analysis shows that international travelers are important sources of infectious diseases. HFRS related to travel and immigration is a rare event. Principal risk factors for travelers and immigrants are camping outside recommended areas or under unsuitable conditions. In recent years, various publications have shown that international travelers and immigrants have expanded the spectrum of imported infectious diseases. The literature data show that the actual reported numbers of imported case of HFRS are limited.

Crimean-Congo hemorrhagic fever with hepatic impairment and vaginal hemorrhage: a case report.

BACKGROUND: Crimean-Congo hemorrhagic fever is a tick-borne disease described in more than 30 countries in Europe, Asia, and Africa. Albania is located in the southwestern part of the Balkan Peninsula. In 1986, the first case of Crimean-Congo hemorrhagic fever was registered, and cases of patients with hemorrhagic fever are rising, and most of them present in a serious condition, when the mortality rate is very high. In districts like Mirdite, Lezhe, Gjirokaster, Skrapar, Erseke, and Kukes, there is delineated human-to-human transmission. CASE PRESENTATION: We report the case of a 32 year-old Albanian woman from a rural area of Albania. She was hospitalized at the Infectious Diseases Service, for a severe influenza-like illness of 4 days duration. Our patient had been bitten by a tick while working in her garden. She presented with nausea, vomiting, headache and muscle pain. A physical examination found a high fever of 40 °C, an enlarged liver, petechia, and vaginal bleeding; flapping tremor and fetor hepaticus were found as a sign for hepatic encephalopathy; and confusion and disorientation were observed in her neurological examination. Her platelet and white blood cell counts were very low, while her aspartate aminotransferase and alanine aminotransferase levels were very high. She was transferred to the intensive care unit because of her worsening condition. Serological and C-reactive protein test results for Crimean-Congo hemorrhagic fever were positive. She was treated with oral ribavirin and discharged with normal parameters. CONCLUSIONS: People in high-risk professions in the endemic areas should be informed and trained on the risk of Crimean-Congo hemorrhagic fever as a matter of urgency. Vaginal bleeding is not always a gynecological problem. In Albania, these places are the mountainous areas, so people who have traveled to these areas and who have symptoms after a tick bite are advised to contact their doctors.

The role of gender in the prevalence of human leptospirosis in Albania.

INTRODUCTION: Leptospirosis is a zoonotic spirochetal disease with global importance, which continues to have a major impact on public health in developing countries. The prevalence of the disease is much higher in males. The objectives of this study were: to give some data and to share our experience with human leptospirosis in Albania; to describe the prevalence regarding to the role of gender in the prevalence of human leptospirosis; to make a gender specific analysis of the clinical manifestations in patients diagnosed and treated for leptospirosis in our service and to make a review of literature related to this hypothesis. METHODOLOGY: We reviewed the epidemiologic data, risk factors and differences in clinical presentation between males and females' patients with leptospirosis. These data are analysed from hospitalized patients. Diagnosis of leptospirosis was established based on clinical presentation, epidemiological data and subsequently confirmed serologically by Anti-Leptospira IgM antibodies through ELISA test. RESULTS: Between 2005-2016, 233 cases of confirmed leptospirosis were analysed. Males were 208 (89.27%) and 25 of patients (10.72%) were females in ratio 9:1 p < 0.001. The highest prevalence was observed in the 45-64 age groups. Overall mortality was found to be 8.58%, 19 were males and one female p < 0.001. CONCLUSIONS: There is a much higher prevalence of leptospirosis in middle aged men. Mortality rate seems to be similar in males and females. While the difference in prevalence may be related to exposure to risk factors, further investigation is necessary to study gender-based genetic and immunological predisposition.

Acute encephalitis as initial presentation of leptospirosis.

Encephalitis is an acute inflammation of the brain matter, very often associated with viral infections, but it can also be caused by non-viral pathogens such as leptospirosis. Leptospirosis is a systemic disease caused by bacteria of the Leptospira genus. Leptospiral infection has a broad spectrum of clinical manifestations ranging from subclinical or mild illness to a fulminant life-threatening illness. In this case report we describe a young patient from Southern Albania with isolated encephalitis caused by Leptospira, where acute encephalitis was the initial presentation of the disease.

Pancreatitis in patients with hemorrhagic fever with renal syndrome: A five-year experience.

INTRODUCTION: Pancreatitis is a rare complication of hemorrhagic fever with renal syndrome (HFRS). The causative agents of HFRS are hantaviruses, which belong to the genus Hantavirus, family Bunyaviridae. The purpose of this study was to evaluate cases of acute pancreatitis (AP) in patients with HFRS at the Service of Infectious Diseases, Tirana, Albania. METHODOLOGY: In this retrospective study, clinical and laboratory data was obtained from 36 patients with confirmed HFRS, between January 2011 and December 2016. The diagnosis had been confirmed by a positive enzyme-linked immunosorbent assay (ELISA) for IgM or IgG antibodies to hantavirus. RESULTS: The average patient age was 39.7 ± 14.1 years with a range of 15-59 years. From 36 HFRS patients, four (11.1%) were found to have AP, all were male. Abdominal pain was the most common symptom and an increase in amylase and lipase was observed in all four patients. Abdominal computed tomography (CT) indicated pancreatitis with surrounding edema, necrosis and hemorrhage. In this study, the total mortality was 11.1% (4/36), while mortality in patients with AP was 25% (1/4). CONCLUSIONS: The results indicate that AP is a serious complication of HFRS, with a poor prognosis. Increased awareness of AP in clinicians and assessment of amylasemia or lipasemia in patients with HFRS should be considered, especially in endemic areas where a rapid diagnosis is crucial for a positive outcome.

Access to Specialized Care Through Telemedicine in Limited-Resource Country: Initial 1,065 Teleconsultations in Albania.

OBJECTIVE: To analyze the initial experience of the nationwide clinical telemedicine program of Albania, as a model of implementation of telemedicine using "Initiate-Build-Operate-Transfer" strategy. METHODS: This was a retrospective study of prospectively collected data from teleconsultations in Albania between January 1, 2014 and August 26, 2015, delivered synchronously, asynchronously, or a combination of both methods. Patient's demographics, mode of consultation, clinical specialty, hospitals providing referral and consultation, time from initial call to completion of consultation, and patient disposition following teleconsultation were analyzed. Challenges of the newly created program have been identified and analyzed as well. RESULTS: There were 1,065 teleconsultations performed altogether during the study period. Ninety-one patients with autism managed via telemedicine were not included in this analysis and will be reported separately. Of 974 teleconsults, the majority were for radiology, neurotrauma, and stroke (55%, 16%, and 10% respectively). Asynchronous technology accounted for nearly two-thirds of all teleconsultations (63.7%), followed by combined (24.3%), and then synchronous (12.0%). Of 974 cases, only 20.0% of patients in 2014 and 22.72% of patients in 2015 were transferred to a tertiary hospital. A majority (98.5%) of all teleconsultations were conducted within the country itself. CONCLUSIONS: The Integrated Telemedicine and e-Health program of Albania has become a useful tool to improve access to high-quality healthcare, particularly in high demanding specialty disciplines. A number of challenges were identified and these should serve as lessons for other countries in their quest to establish nationwide telemedicine programs.

Ocular and cutaneous manifestation of leptospirosis acquired in Albania: A retrospective analysis with implications for travel medicine.

UNLABELLED: Albania is an attractive tourism destination with an increasing volume of travel. As a Mediterranean country some tropical infectious diseases are present in certain areas of Albania, including leptospirosis, which is a zoonotic infectious disease prevalent around the world. The goal of this retrospective study is to describe the ocular and cutaneous manifestations of leptospirosis in Albanian patients and raise awareness to travelers travelling in and out of the country. METHODS: We retrospectively studied 107 cases of leptospirosis, treated at "Mother Teresa" University Hospital Center, in Tirana, Albania between January 2009 and December 2014. All cases included in the analysis had a clinical and epidemiological presentation suggestive of leptospirosis, confirmed with ELISA (enzyme linked immunoassay) positive for IgM antibodies against Leptospira. RESULTS: There were 89.7% males (n = 96) and 10.2% females (n = 11). Mean age at the time of diagnoses was 43.7 ± 17.8 years old (range 17-78). All patients were native and residents of Albania. Conjunctival suffusion was present in 81.3% of the cases, whereas subconjunctival hemorrhage was seen in 12 patients (11.2%). Uveitis was seen in 38.3% of the cases and all patients with uveitis presented a severe systemic disease. A cutaneous rash was present in 58.8% of patients. Other cutaneous manifestations include jaundice in 62.6% and intense pruritus in 5.6% of cases. CONCLUSIONS: Ocular and cutaneous involvement happens more frequently in patients with Leptospirosis, than it was thought to be. Therefore the clinician should be more careful in his systemic evaluation of the disease.

A study on the epidemiology and aetiology of acute gastroenteritis in adult patients presenting at the infectious diseases hospital in tirana, Albania.

BACKGROUND: Acute gastroenteritis remains a common cause of hospital emergency room visits in Albania. However, the aetiology of severe gastroenteritis leading to hospitalization in adults frequently remains unclear. AIMS: Our objective was to study the epidemiology and causes of community-acquired, acute gastroenteritis in adult patients presenting to hospital. STUDY DESIGN: Cross sectional study. METHODS: A prospective study was conducted from January 2010 to January 2012, among patients ≥15 years old with community-acquired gastroenteritis presenting to the emergency room of the University Hospital "Mother Theresa" in Tirana, Albania. Stool samples and rectal swabs were collected from the patients for microbiological testing. RESULTS: The median age of the study patients was 33 (15-88) years and 577 (58%) were females. The median age of males was 35 (15-87) years. The vast majority of cases occurred in urban area (849, 85%), p<0.01. Patients were admitted throughout the year with peak admissions for patients infected by bacterial pathogens in summer and those affected by viral pathogens in autumn. A total of 917 (91.7%) patients underwent a laboratory examination. The overall isolation rate was 51%. Bacterial pathogens were found in 29%, viral pathogens in 19% and protozoal pathogens in 2.5% of patients. No aetiological agent or other cause of acute diarrhoea was found in 449 (49%) patients. Twenty-nine (3.2%) patients were hospitalized. CONCLUSION: Despite extensive laboratory investigations, enteropathogens were detected in only 51% of adult patients who presented to the hospital ER with acute gastroenteritis. Viral infections ranked as the second most common cause of gastroenteritis in adults.

Hemorrhagic fever with renal syndrome associated with acute pancreatitis.

Hemorrhagic fever with renal syndrome (HFRS) is a systemic infectious disease caused by Hantaviruses and characterized by fevers, bleeding tendencies, gastrointestinal symptoms and renal failure. It encompasses a broad spectrum of clinical presentations, ranging from unapparent or mild illnesses to fulminant hemorrhagic processes. Among the various complications of HFRS, acute pancreatitis is a rare find. In this report, based on clinical data, laboratory and radiologic examination findings, we describe a clinical case, with HFRS from Dobrava virus, associated with acute pancreatitis. The patient was successfully treated by supportive management. Clinicians should be alert to the possibility of HFRS when examining patients with epidemiological data and symptoms of acute pancreatitis.

Current status of transplantation and organ donation in the Balkans--could it be improved through the South-eastern Europe Health Network (SEEHN) initiative?

Organ donation and transplantation activity in the majority of Balkan countries (Albania, Bosnia and Herzegovina, Croatia, Macedonia, Moldova, Montenegro, Serbia, Romania and Bulgaria) are lagging far behind international averages. Inadequate financial resources, unclear regional data and lack of government infrastructure are some of the issues which should be recognized to draw attention and lead to problem-solving decisions. The Regional Health Development Centre (RHDC) Croatia, a technical body of the South-eastern Europe Health Network (SEEHN), was created in 2011 after Croatia's great success in the field over the last 10 years. The aim of the RHDC is to network the region and provide individualized country support to increase donation and transplantation activity in collaboration with professional societies (European Society of Organ Transplantation, European Transplant Coordinators Organization, The Transplantation Society and International Society of Organ Donation and Procurement). Such an improvement would in turn likely prevent transplant tourism. The regional data from 2010 show large discrepancies in donation and transplantation activities within geographically neighbouring countries. Thus, proposed actions to improve regional donation and transplantation rates include advancing living and deceased donation through regular public education, creating current and accurate waiting lists and increasing the number of educated transplant nephrologists and hospital coordinators. In addition to the effort from the professionals, government support with allocated funds per deceased donation, updated legislation and an established national coordinating body is ultimately recognized as essential for the successful donation and transplantation programmes. By continuous RHDC communication and support asked from the health authorities and motivated professionals from the SEEHN initiative, an increased number of deceased as well as living donor kidney transplantations in the future should be more realistic.

Hemorrhagic fever with renal syndrome complicated by orchitis.

Hemorrhagic fever with renal syndrome (HFRS) is a disease caused by viruses of the family Bunyaviridae, genus Hantavirus. HFRS from Dobrava virus (DOBV) is a seldom reported disease in Albania. Clinically HFRS is manifested as mild, moderate, or severe. Therefore, the number of cases of Hantavirus' infection may be underestimated, and should be included in the differential diagnosis of many acute infections, hematologic diseases, acute abdominal diseases and renal diseases complicated by acute renal failure. We report here an atypical presentation of HFRS from Dobrava virus complicated by orchitis with a positive outcome.