A SEVERE CASE OF NON TYPHOIDAL SALMONELLA ASSOCIATED WITH MULTIPLE ORGAN DAMAGE- CASE STUDY AND LITERATURE REVIEW.

We report a severe case of a 25-year-old girl presented with complaints of weakness, diarrhoea, vomiting, pain in abdomen and hypotension at Infectious Diseases and Clinical Immunology Research Center. From history on 25 February till 29 February she was in India and on 1 march this problem started with watery diarrhoea followed by vomiting. She ate pizza with mushroom following which her condition worsened. Stool culture revealed salmonella nontyphi (nonthyphodal Salmonella)and this is leading cause for gastroenteritis, bacteremia and affects several other bodily system. Her condition deteriorated due to the development of ARDS (acute respiratory distress syndrome) and for this she was on mechanical ventilation. Vitec machine was performed, which identified Salmonella typhi murium. Our goal is to manage and treat this patient well by early diagnosis. She was given ceftriaxone, iv fluids and symptomatic treatment but due to resistance meropenem was started and the patient's condition improved. From serology there was no evidence of immunocompromised state so being a severe case of immunocompetent patient this case reflects the importance of timely diagnosis and management together with food safety practices in population. On follow up she was stable and discharged after 3 weeks. Future research studies need to be continued regarding newer strains, effective treatment strategies and diagnostics to prevent morbidity and mortality.

ENTEROHEMORRHAGIC ESCHERICHIA COLI LEADING TO HAEMOLYTIC UREMIC SYNDROME - CASE STUDY AND REVIEW.

Escherichia coli is a gram-negative bacillus and considered to be the normal pathogen of intestinal and extraintestinal manifestations depending upon the strain. A variety of strains exist that are responsible for causing myriads of clinical presentation. E.coli O157: H7 being the most common and severe bacterial pathogen is the leading cause of bloody diarrhea. EHEC (Enterohemorrhagic E.coli) is responsible for causing severe complications like HC (Hemorrhagic colitis). Herein, we present the case of a young girl with E.coli O157:H7 infection and review the related literature. A previously healthy 37-year-old female presented with bloody diarrhea, fever, headache, and lower abdominal pain. As per history she had eaten a hamburger, denied any recent travel and absence of inflammatory bowel disease or bloody stools in family history. Physical examination revealed normal vital signs and the physical findings were unremarkable except for severe abdominal pain. Her stool was hem-occult positive. The complete blood count was within normal limits except neutrophilia and leukocytosis. An abdominal ultrasound showed thickened bowel loops consistent with colitis. First week of her hospital course, she continued to have bloody diarrhea and severe abdominal pain. Her final stool submitted to the laboratory on day 7 was consistent with a blood clot, following her developed low urine output and hematuria, with a serum creatinine of 2.1 mg/dl on day 5. Her renal symptoms were treated with fluids. She was given supportive treatment, and her platelet count and hemoglobin were stabilized. In early stages of bloody diarrhea, parental hydration plays a major role in accelerating volume expansion. Rapid stool analysis for these bacteria can alert specialists to deal with severe complications like HUS.

DISTRIBUTION OF HBV GENOTYPES AMONG GEORGIAN PATIENTS OF DIFFERENT AGE GROUPS.

Hepatitis B virus (HBV) infection is one of the major healthcare problems in Georgia with a prevalence of 2.9% in the adult population. There is no published data on HBV genotype distribution among different age groups in the country. The study aims to evaluate genotype distribution in Georgian HBV-infected patients among different age groups. Data was extracted from the clinical database of Mrcheveli medical center. Genotyping was performed using INNO-LiPA methodology. Statistical analysis was done using the statistical software SPSS 23.0. The total number of patients enrolled in the study was 84, of which 52 (62.1%) were males. Participants were mostly from Tbillisi (63.2%, N=53). Even though HBV genotype D was more predominant (found in 57.1% (N=48) of study participants), than genotype A (found in 42.9% (N=36) of the study population). Age was significantly associated with genotype distribution. The majority of the participants (58.3%, N=49) were 35 years old or younger. Genotype D was predominant in 71.4% of the study participants older than 35 years old, versus 46.9% of individuals 35 or younger with genotype D (p<0.001). Genotype A, among those <35 and >= 35 was presented in 53.1% and 28.6% of cases, respectively. Our data suggests that HBV genotype D is most prevalent among older Georgian patients chronically infected with hepatitis B. More than half of younger patients (35 years old or younger) have Genotype A.

[HBV as one of the causes for development of cholelithiasis].

The aim of this study was to identify the influence of HBV on gall bladder and to establish necessity and terms of preventive measures. For this reason we have examined 58 patients, passed through cholecystectomy and 142 patients with B hepatitis. Patients of this group were followed up during 18 months. In the first group presence HBsAg in the gall bladder tissue was identified using immunoferment analysis and immunofluorescent testing. In all cases the blood was tested for specific markers (HBsAg, Anti-HB-cor antibodies of G and M classes). In the second group 75 patients were investigated prospectively. Observation using ultrasound was performed to find out the changes of gall bladder and bile. In this group preventive measures against gallstone formation were performed. 67 patients were investigated retrospectively and prevention was not performed among them. In 10 cases of cholecystectomy (17,2%) out of 58, HBsAg in the gall bladder tissue was identified both, with immunoferment analysis and immunofluorescent testing. The ultrasound examination revealed morpho-functional changes of gall bladder and bile in the acute stage of hepatitis B and also in following period. There were no cases of development of gallstones in the group where preventive measures using dietary fiber-rich food "Margi" were conducted, in the second group, where such measures have not been performed, gallstones developed in 5 patients (7,46%) out of 67, during 6-18 months after the acute B hepatitis. This results allow us to conclude, that cholecystopathogenic influence of HBV leads to the morpho-functional changes of gall bladder. This fact must be assessed as a risk factor for development of cholelithiasis and confirms necessity of early longlasting preventive measures.

Re-treatment of patients with hepatitis C who failed to respond (nonresponders) to previous treatment.

The aim of four-year follow up study was evaluation of re-treatment efficacy of antiviral therapy in patients with hepatitis C who failed to respond (non responders) to previous therapy. Study enrolled 29 patients, aged 21-59 with HCV infection (15 had HCV genotype 1, and 14 had HCV non-genotype1), who previously were treated with unmodified interferon alfa (conventional interferon) 2a or 2b 5 MIU TIW plus ribavirin (1000-1200 mg/day) and who failed under this therapy. Study subjects were randomized into two groups: in group I were included 17 patients--relapsers (patient in whom HCV RNA becomes undetectable on treatment and is undetectable at the end of therapy, but is detected again after discontinuation of treatment). Group II was composed of 12 patients: 4 were non responders (patient in whom HCV RNA levels remain stable on treatment), 4--partial responders (HCV RNA levels decline by >2 logs, but never become undetectable during treatment) and 4--breakthrough non responders (HCV RNA become undetectable during treatment, but before-treatment termination again become detectable). The diagnosis of HCV infection was made based on detection of HCV antibodies by ELISA and confirmed by RIBA. Detection of HCV RNA (qualitative) and HCV RNA Viral load--by Real time PCR technique (COBAS TaqMan Test). HCV genotypes were detected by INNO-Lipa method. In group I--rapid virological response (RVR) was observed in 10 (58%) patients, early viral response (EVR) in 12 patients (70%). Among them 9 (52%) patients remained HCV RNA undetectable by the end of treatment. After 6 months sustained viral response (SVR) was received in 7 (41%) patients from group I. In group II--RVR was observed in 5 (41%), EVR in 6 (50%) patients. Among them 5 (41%) patients remained HCV RNA undetectable by the end of treatment. After 6 months Sustained Viral Response was received in 3 (25%) patients. Re-treatment with pegylated interferon and ribavirin in patients with hepatitis C who failed to responds to previous treatment was effective in relapsers. Re-treatment in non responders, partial responders and breakthrough non responders was less effective (especially in non responders). Re-treatment effectiveness was higher in HCV genotype non 1 patients in comparison with HCV genotype 1. Thus re-treatment will be considered for relapsers. For making decision on re-treatment for other nonresponders, severity of disease (advance disease) should be considered.

Fibroscan and FibroTest/FibroMax to assess liver fibrosis/cirrhosis in patients with chronic HBV and HCV infection in Georgia.

Although, liver biopsy is the gold standard in assessment of the degree of liver damage, the method has some limitations. For this reason, assessment of liver damage using non-invasive methods is currently an important topic in hepatology. The aim of the study was to evaluate liver fibrosis/cirrhosis using Transient Elastography and FibroTest/FibroMax in patients with chronic HCV and HBV infection in Georgia and to compare Fibroscan and FibroTest/FibroMax results. 252 patients were included in the study, among them 185 with chronic HCV infection and 67 with chronic HBV infection. These patients were investigated at the Georgian-French Joint Hepatology Clinic "Hepa", from December 2007 to November 2008. In patients with chronic HCV or HBV infection Fibroscan and Fibrotest/FibroMax results were correlated in 127 (68.6%) and 45 (67.2%) cases, respectively. Discordance in one degree of fibrosis stage was found in 36 (19.5%) patients with chronic HCV infection and in 14 (20.9%) patients with chronic HBV infection. Discordance in more then one degree of fibrosis stage was found in 22 (11.9%) and 8 (11.9%) cases. In patients with Fibroscan and Fibrotest/FibroMax concordant results liver biopsy might be avoided. Fibroscan and Fibrotest/Max appear to be very valuable methods for detecting early stages of fibrosis among patients with chronic HCV and HBV infection, allowing to avoid the progression of liver damage, as well as end-stage liver disease. These methods are easy to perform and therefore allows regular follow-up of the course of LF.

[Side effects of the combined antiviral therapy in patients with chronic hepatitis C].

The aim of the study is to reveal and treat the side effects of the combined antiviral therapy - Peginterferon and Ribavirin in patients with chronic Hepatitis C. During 2004-2006 years, 40 patients in the ambulatory department of the Infectious Diseases Clinic of the State Medical University were investigated. All the patients were administered pegilated interferon and ribavirin after special procedures. The following side effects on the antiviral treatment were grouped: flu-like, cardiovascular, gastrointestinal, neuro-psychiatric, dermatological and hematological. Frequency, severity and duration of all unfavorable symptoms were independent of Hepatitis C genotype, though the adherence to the medications was better in younger age groups and the dose correction where required after the age 45.