Pancytopenia as the main manifestation of human immunodeficiency virus infection in the AIDS stage The authors present a case.

The authors present a case report of 59-years-old woman examined for pancytopenia recently diagnosed during hospitalization for bilateral interstitial pneumonia without any confirmed etiological agents. Concomitantly, some systemic symptoms like lack of appetite and weight loss were present. Primary hematological disease was ruled out. Positivity of serological screening for HIV-1,2 was rather surprising. Absolute count of CD4+ lymphocytes was 8/μl. Thus, HIV infection was already in stage of AIDS and retrospectively, the interstitial pneumonia has to be judged as AIDS-indicative illness.

Pembrolizumab-induced hypothyreosis and subcutaneous bleeding.

Pembrolizumab belongs to so called immune checkpoint inhibitors. Frequent adverse event of this therapy is hypothyroidism. The authors present a case report of patient treated with pembrolizumab for non-small cell lung carcinoma, in whom severe hypothyroidism followed quite rapidly after transient phase of subclinical hyperthyroidism - at this time point new and spontaneous onset of large subcutaneous hematomas was observed. Acquired von Willebrand syndrome, acquired hemophilia A, dysfibrinogenemia, activation of fibrinolysis and thrombocytopathy were all actively ruled out in hematological differential diagnosis. Concomittantly, laboratory markers of secondary autoimmune disease and myositis were excluded. Despite continuous pembrolizumab treatment, there were no other bleeding complications seen after intensification of endocrine substitution therapy with thyroid hormones. Causal relationship between subcutaneous hematomas and severe drug-induced hypothyroidism is established per exclusionem.

Heparin-induced thrombocytopenia: a case report and literature overview.

Heparin-induced thrombocytopenia (HIT) is an immunologically-mediated complication, which usually follows heparin exposition, less frequently exposition to other drugs or even occurs spontaneously. The type of heparin, its dose and mode of application as well as the exposition time, major trauma or operation, and obesity represent the main risk factors for HIT. The probability of HIT correlates with so-called 4T-score. A confirmatory laboratory diagnostic should be exclusively reserved for patients with a medium to a high probability of HIT development (more than 3 points in 4T-score). The screening method is based on serological detection of antibodies against heparin-platelet factor-4 complexes; confirmation tests aim to identify the activation of platelets. The treatment of HIT requires an immediate interruption of heparin application and rigorous antithrombotic treatment with an alternative agent. Herein authors describe a clinical case of HIT manifested as an extreme urticarial reaction in the location of nadroparin application as well as thrombosis of deep subcutaneous veins in a polymorbid obese patient with an extensive and infected burn. Due to timely diagnosis and fondaparinux treatment, no more severe thrombotic events occurred in this patient.

Liver transplantation as potential curative method in severe hemophilia A: case report and literature review.

The authors present clinical case of orthotopic liver transplantation for cirhosis due to chronic viral hepatitis C in a subject with severe hemophilia A. Preoperatively performed pharmacokinetic study with recombinant F VIII confirmed satisfactory in vivo recovery of 2.1 %. A bolus application of 52 units F VIII/kg body weight with target F VIII activity over 100.0 % was administred shortly before the transplantation started. Totally, 30 000 units of recombinant F VIII, 3 thrombocyte concentrates, 2 erythrocyte concentrates, 5 units of virally inactivated plasma, 1 unit of fresh frozen plasma and 3 500 antithrombin units were used. There were no perioperative or postoperative bleeding complications, F VIII substitution was stopped on postoperative day 3. The patient was discharged on twentieth postoperative day.

Pancytopenia, panhypopituitarism and liver cirrhosis: analysis of a difficult clinical case.

Panhypopituitarism following craniopharyngioma resection has systemic impact with potential influence on physio-logical hematopoiesis. There is a growing body of evidence of liver fibrosis/cirrhosis risk development due to altered metabolism and lipid accumulation. The authors present a case report of a woman with a history of craniopharyngioma resection followed by aggravating pancytopenia with suspected indolent lymphoproliferative disorder and possible acquired bone marrow aplasia syndrome due to paroxysmal nocturnal hemoglobinuria. A complex hemostasis disorder with deficiency of multiple coagulation factors (FXII, FXI, FX, FIX, FVII, FX, FV, FXIII, antitrombin, protein C, protein S) was accidentally detected. Despite normal sonographic liver imaging, all possible causes of chronic liver disease were systematically excluded (viral hepatitis, hemochromatosis, Wilson´s disease, α-1-antitrypsin deficiency); anti-LKM-1 and anti-ENA antibodies were detected. Finally, the magnetic resonance imaging confirmed image of liver cirrhosis - with signs of portal hypertension.

[Is it necessary to revaccinate against hepatitis B virus when the titer of anti-HBs drops below 10 IU/L?]

Viral hepatitis B still represents a major epidemiological issue worldwide. After recombinant vaccine administration, a titer of anti-HBs antibodies ≥ 10 IU/L has long been considered to be seroprotective. Persons without this antibody level after complete vaccination are referred to as non-responders. A progressive decline in anti-HBs levels over years is also commonly seen in responders. Recently, there has been increasing evidence that the titer of anti-HBs ≥ 10 IU/L does not provide 100 % protection against infection and clinically manifest illness. Additionally, an important role of cellular immune memory has been demonstrated - without any correlation with anti-HBs titer. Based on current knowledge, there is no need for regular anti-HBs titer testing or booster vaccination in immunocompetent individuals with anti-HBs ≤ 10 IU/L. At present, regular serological testing and, if need be, revaccination to maintain anti-HBs ≥ 10 IU/L are recommended in immunocompromised persons and after liver transplantation.

[Treatment with rituximab as an opportunity for the prevention of infectious complications]. / Lécba rituximabem jako výzva k prevenci infekcních komplikací.

UNLABELLED: Rituximab, a monoclonal antibody against the surface antigen of B-lymphocytes CD20 is beeing used in the treatment of numerous hematological, hematooncological and autoimmune disorders. After administration of ritu-ximab, quick and almost complete depletion of B-lymphocytes with the exception of pre-B-lymphocytes and plasma cells occur. Neutropenia and low serum antibody levels in classes IgA, IgM and IgG may also develop. These changes usually persist for 6-12 months, rarely for several years. In the consequence, patients with the rituximab treatment are more prone to infections - usually of bacterial and viral origin. Concomitantly, rituximab treatment influences negatively postvaccination antibody production and therefore adequate preventive measures are necessary before the beginning of the treatment. The authors offer complex overview of actual literature, emphasize adequate education of patients as well as of healthcare providing staff and discuss the vaccination recommendation against preventable communicable diseases like influenza, pneumococcal diseases, tetanus, diphtheria and pertussis. KEY WORDS: autoimmune disease - immunosupression - infectious complications - prevention - rituximab - vaccination.

[Severe osteoporosis - the story of chronic medication-related hyponatremia]. / Tezká osteoporóza aneb Príbeh chronické polékové hyponatremie.

The authors present a case-report of a 73 years old woman treated for arterial hypertension within past 15 years with diuretics (thiazides, amiloride and indapamide) and concomitantly with antidepressive trazodone. The patient developed severe osteoporosis after 6 years of such a treatment with multiple fractures even after minor trauma; during whole this period severe hyponatremia without adequate supplementation was documented. Most probably, there exists tight relationship of osteoporosis and hyponatremia in this patient - the authors discuss possible pathophysiological mechanisms at the level of renal tubules, osteoblasts and osteoclasts, hypopituitary-skeletal axis, syndrome of inadequate adiuretin secretion (SIADH) and possible influence of acid-base balance disturbances.

[When should empirical antibiotic therapy be indicated in acute community-onset diarrhea of suspected bacterial etiology]. / Kdy indikovat empirickou antibiotickou lécbu u akutní komunitní gastroenyerokolitidy suspektní bakteriální etiologie?

BACKGROUND: The aims of this study were to describe the basic parameters of adult patients with acute community-onset salmonellosis or campylobacteriosis responsible for more than 90 % of all cases of community-onset diarrhea in the Czech Republic, and, according to the results of this analysis, to update the diagnostic and therapeutic algorithms. MATERIALS AND METHODS: The data were collected retrospectively between January 1, 2011 and December 31, 2013. Patients with systemic signs of infection having at least 2 signs of systemic inflammatory response syndrome (SIRS) or with elevated serum procalcitonin levels (more than 0.5 ng/ml) were classified as being at risk for the invasive form of the disease. The remaining patients were classified as having the simple intestinal form of the disease. Patients with community-onset post-antibiotic diarrhea were excluded. The data were statistically processed. RESULTS: The following clinical factors were statistically significantly correlated with the high-risk form of the disease: duration of illness of less than 3 days before admission and any of the following (some of them are part of the SIRS classification), even after being adjusted for age: body temperature above 38 °C, peripheral blood white cell count (WBC) above 12 × 109/l, neutrophil count above 9 × 109/l and CRP level above 150 mg/l. The risk form of the disease occurred in 60 cases (18.7 %). The mean WBC was 9.4 × 109/l (median, 8.4; range, 1.7-89.0). The WBC within the normal range was seen in 194 cases (60.4 %). The mean CRP level was 92.9 mg/l (median, 77.0; range, 1.0-342.0). An elevated procalcitonin level was seen in 21 patients; the marker was not routinely measured. Positive blood culture results were obtained in 2 persons with salmonellosis; the examination was not routinely performed. There were 34 patients (10.6 %) with documented immune system dysfunction; the risk form of salmonellosis or campylobacteriosis was seen in only 11 of them (3.4 %). A total of 306 patients (95.3 %) were treated with antibiotics; the mean duration of antibiotic therapy was 8.7 days (median, 7; range, 2-31). CONCLUSIONS: Antibiotic treatment in salmonellosis/campylobacteriosis should not be indicated only due to elevated CRP levels but rather after comprehensive evaluation of the duration of symptoms, individual risk factors and dynamic changes in markers of inflammation. Blood culture tests should be carried out more frequently.

[Campylobacteriosis]. / Kampylobakterioza

Campylobacteriosis belongs to the most frequent bacterial gastrointestinal infections worldwide. In the past several years, an increasing trend in the prevalence of campylobacteriosis has been observed in many countries. The rapid spread of antibiotic resistance in Campylobacter spp. also poses a major challenge. The authors review current knowledge on the microbiology of Campylobacter spp., complex pathogenetic as well as pathophysiological mechanisms in the development and course of campylobacteriosis and related complications such as Guillain-Barré syndrome.

[RILPIVIRINE -- a novel HIV-1 non-nucleoside reverse transcriptase inhibitor]. / RILPIVIRIN -- nový nenukleosidový inhibitor reverzní transkriptázy HIV-1.

The article summarizes the basic facts about the pharmacokinetic profile, metabolism and drug interactions of rilpivirine (RPV). This is the latest orally administered second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) for antiretroviral-naive patients with HIV-1 infection. Conformational flexibility and adaptability are the factors that dominantly determine the high resistance barrier of RPV and are the unique features of diarylpyrimidine inhibitors (DAPY inhibitors - 2nd generation NNRTIs). Multicentre studies ECHO and THRIVE are also reviewed. Current guidelines for the treatment of HIV/AIDS are mentioned as well as the role of RPV in current therapeutic regimens.

Acute toxoplasmosis-etiological factor for development of Hodgkin's lymphoma?

The case of an HIV-positive man treated for acute toxoplasmosis with no traces of malignancy is reported. A second lymph node extirpation was performed after 5 months, which identified the presence of Hodgkin and Reed-Sternberg (HRS) cells. This case suggests that toxoplasmosis may cause changes in the regulation of surrounding cells and induce neoplastic proliferation.

Surgical treatment of Clostridium colitides.

INTRODUCTION: Infection with Clostridium difficile (CDI) is the most frequent cause of nosocomial diarrhoeas. Most cases are successfully treated by antibiotic therapy, but nearly 10% may progress to the fulminative form of this condition. The objective of the work is retrospective evaluation of the results of surgical treatment in patients with the fulminative form of Clostridium colitis with revealing of risk factors leading to serious post-operative morbidity and mortality. PATIENTS AND METHODOLOGY: Retrospective evaluation of the results of surgical treatment in patients with the fulminative form of Clostridium colitis between 2008 and 4/2012. RESULTS: Between 2008 and 4/2012 Clostridium toxins were positively detected in 1,088 patients in total, 21 of whom underwent operations due to the fulminative form of Clostridium colitis. The operations included 4 total colectomies with terminal ileostomy, 15 subtotal colectomies with terminal ileostomy, 1 caecostomy and 1 axial ileostomy. The 30-day mortality was 23.8%, and morbidity reached 66.6%. High leukocytosis is a statistically significant predictor of post-operative mortality and morbidity (p = 0.008). CONCLUSION: Early indication for a colectomy operation with terminal ileostomy in patients with the fulminative form of Clostridium colitis leads to lower morbidity and mortality.

[Incidence of leptospirosis in Pardubice and Hradec Králové region and a part of Vysocina region in the years 2002-2009]. / Výskyt leptospirózy v Kralovehradeckem a Pardubické m kraji a v cásti kraje Vysocina v letech 2002-2009.

BACKGROUND: The aim of this study was to evaluate the incidence of leptospirosis in Pardubice and Hradec Králové regions and a part of Vysocina region in 2002-2009. A group of patients was statistically analyzed and the incidence rates of leptospirosis in individual months and years were calculated. MATERIAL AND METHODS: A group of 4,813 patients with suspected leptospirosis from Pardubice and Hradec Králové regions and a part of Vysocina region were examinated in our centre in 2002-2009. A total of 5,366 biological samples were studied. From 4,625 blood samples, 3,958 were examinated with the serological microagglutination-lysis method and the remaining 667 with the PCR method. RESULTS: From 4,813 patients suspected to have leptospirosis, 89 were found to be leptospirosis-positive. Leptospirosis was diagnosed in 63 males (70.7 %) a 26 females (29.3 %); the mean age were 39.52 ± 17.67 years in males and 46.85 ± 18.34 years in females; the mean age men + women was 41.66 ± 18.13 years (range 3-78 years). Most positive male patients (n = 28) were in 26-45 age group; the findings were similar in females (n = 10). The highest number of leptospirosis cases was noted in 2005. Most frequently, infection caused by pathogenic leptospires was diagnosed in November. CONCLUSION: The incidence rates of leptospirosis in Pardubice and Hradec Králové regions and a part of Vysocina region in 2002-2009 (with the exception of 2008) exceeded the overall reported levels 0.4/100,000 population.

[Disseminated infection with Mycobacterium avium in a patient with newly diagnosed HIV infection]. / Diseminovana infekce Mycobacterium avium u pacienta s nove zjistenou HIV infekci.

In the Czech Republic, mycobacteriosis is relatively rare. The low incidence probably reflects high BCG coverage rates in the Czech population. Globally, the importance of BCG vaccine has been increasing, as a result of acquired immunodeficiencies, particularly HIV infection. The presented case report describes the course of disseminated mycobacteriosis in a Vietnamese asylum seeker with newly diagnosed advanced HIV infection. In HIV patients, disseminated mycobacteriosis, most frequently caused by members of Mycobacterium avium complex (MAC), is mostly manifested in the last stage, AIDS, with extremely severe immunodeficiency, or in immune reconstitution inflammatory syndrome (IRIS), shortly after initiation of antiretroviral therapy. From the beginning, the patient's condition was complicated by multiple simultaneous severe opportunistic infections which, together with gradually progressing atypical mycobacteriosis, resulted in overall exhaustion of the organism. The adverse prognosis of these infections is significantly influenced by prolonged diagnosis based on culture detection of slow-growing mycobacteria. In the above patient, the lethal course was contributed to by resistance to commonly used antitubercular drugs which was only detected post mortem due to time-consuming susceptibility tests.

[A study of patients with Clostridium difficile infection hospitalized at Brno Clinic of Infectious Diseases in 2007-2010]. / Analýza souboru pacientu s onemocnením vyvolaným toxinem Clostridium difficile hospitalizovaných na Klinice infeckcních chorob v Brne v letech 2007-2010.

BACKGROUND: To describe a set of patients hospitalized at the Clinic of Infectious Diseases of the University Hospital Brno with Clostridium difficile infection (CDI), to interpret clinical and epidemiological data, and to determine the risk factors for the disease and its complications. MATERIAL AND METHODS: A retrospective study of 284 patients with confirmed diagnosis of Clostridium difficile infection hospitalized between 1 January 2007 and 31 December 2010. Epidemiological, clinical and laboratory data were collected from their clinical documentation. RESULTS: Of the 284 patients with a mean age of 73.2 years, 38.0 % were men. Risk factors for developing CDI include the use of antibiotics in the previous 8 weeks (89.1 % of patients), age over 65 years (77.6 %), hospitalization in the previous 4 weeks (65.5 %), and the use of proton pump inhibitors (41.9 %). Recurrence was noted in 89 (31.3 %) cases. Sixty-six (23.2 %) patients required intensive care and 50 (14.6 %) patients died during their hospitalization. Isolates of C. difficile from the stool of 4 patients were sent for ribotyping and identified as ribotype 176. CONCLUSIONS: The CDI rates at the clinic KICH have increased in the recent years. The rise is consistent with the global trends. The study confirmed the disease risk factors reported in the literature. The disease is associated with a high percentage of relapses and complications.

[First experiences with faecal bacteriotherapy in the treatment of relapsing pseudomembranous colitis due to Clostridium difficile]. / První zkusenost s fekální bakterioterapií v lécbe relabujíci pseudomembranózni kolitidy zpusobené Clostridium difficile.

BACKGROUND: The aim was to prove the effectiveness and safety of faecal bacteriotherapy in the treatment of relapsing pseudomembranous colitis due to Clostridium difficile in clinical practice. METHODS: The protocol of faecal bacteriotherapy was adopted from foreign authors (Bakken JS, Aas J, MacConnachie AA). After six months, the success rate was not satisfying and the method was modified so that 40-50 g of stool were administered instead of 20-30 g. RESULTS: A total of 77.8 % of patients included in the study were successfully treated. The study achieved results comparable with foreign literature where the lowest success rate is about 80 %. Neither complications nor death were noticed (0 % mortality rate). CONCLUSIONS: Faecal bacteriotherapy is a safe and simple method capable of curing chronically relapsing forms of pseudomembranous colitis.

[Kaposi's sarcoma]. / Kaposiho sarkom.

Kaposi's sarcoma (KS) is an unusual form of tumor which in the era of HIV/AIDS pandemic is increasingly observed outside the original endemic areas. It was shown that the development of KS is in directly related to infection with human herpes virus 8 (HHV-8). The pathophysiology of KS is complex and is influenced by HIV co-infection and by global cytokine interactions. Skin, gastrointestinal tract and respiratory organs are typically involved. A good therapeutic effect of combined antiretroviral therapy (cART) was documented. We provode a review of the current knowledge of the pathophysiology of and therapeutic options for KS and one clinical case.