Authors : Gherlan G.1, Neata M.1, Kosa A.1, Calistru P.1
1 "Victor Babes" Clinic, Bucharest

The use of noninvasive methods for the quantification of liver fibrosis stage allows now to monitor from this point of view patients with chronic viral hepatitis. The present study intends to evaluate the evolution of liver fibrosis stage during hepatitis C treatment.
In this study were included a number of 24 patients which ended their alpha 2a peginterferon plus ribavirin treatment for chronic hepatitis C between 01.03.2009 and 01.03.2010. In these patients we asessed fibrosis by fibroscan, and by calculating Forns, APRI and FIB-4 fibrosis scores at the beginning of the treatment and 12 months later regardless the treatment's duration. We had 3 nonresponders, one stopped at 3 months, the other two stopped at 6 months. The biochemical markers at the final of the treatment were taken in the week following the last shot of interferon in the patients treated for 12 months.
The best correlation between fibroscan at treatment start and a biochemical score was with FIB-4 (r=0.654, p=0.0005). APRI was also found to be correlated with fibroscan (r=0.546, p=0.0047). Forns score was not correlated with fibroscan. APRI and FIB-4 showed a very good correlation at start (r=0.8938, p<0.0001) and at 12 months (r=0.8328, p<0.0001).
We considerred the following cut-off values for fibroscan : F1, F2, F3, F4 - 5.5kpa, 7.1kpa, 9.5kpa, 14.5kpa. In 18 patients fibroscan values fell at the end of treatment, in 5 the values raised, in one the value was exactly the same. According to the cut-off values above, Metavir corresponding score fell only in 10 patients and raised in two.
The biochemical markers showed the following outcome : Forns raised in 17 patients, FIB-4 raised in 18 and APRI raised in 5 patients, not correlated with fibroscan.
The biochemical scores are affected by the transient modification induced by treatment, making them less useful during this influence. Based only on fibroscan, fibrosis grade improves in 47.6 % in one year of successful treatment.
Keywords : fibrosis, noninvasive, chronic hepatitis, hepatitis C virus, interferon, ribavirin.

Authors : Voineag M.1
1 "Victor Babes" Clinic, Bucharest

Several extrahepatic manifestations have been reported in the natural history of chronic hepatitis B and C. Up to 40 - 74 % of patients infected might develop at least one extrahepatic manifestation during the course of their disease: mixed cryoglobulinemia, non-hodgkin lymfoma, porphyria cutanea tarda, lichen planus, hypothyroidism, lymphocytic sialoadenitis, diabetes mellitus.
ENT manifestations are less frequently, but clinicians must be aware of those pathologies. Effects on the nose are poorly defined; histological studies revealed nasal epithelial erosion and subepithelial non-specific inflammation and/or fibrosis. This changes, combined with abnormalities determined in coagulation lead to recurrent nasal bleeding.
The most common oral mucosal lesions included candidiasis and leukoplakia, but, in all studies, only the association of oral lichen planus with hepatitis C and B virus infection proved to be statistically significant.
Sudden hearing loss has been frequently reported in HCV patients undergoing interferon alpha monotherapy. There are a few cases of a patients with chronic HCV infection and sensorineural hearing loss associated with PEG-IFN alpha and ribavirin combination therapy.
Keywords : extrahepatic manifestation, nasal bleeding, leukoplakia.

Authors : Mandache E.1
1 "Carol Davila" Clinical Hospital for Nephrology. "Victor Babes" National Institute for Research and Development in the Field of Pathology and Biomedical Sciences

It is well-known that the renal parenchyma is involved in the pathologic process of hepatitis with both HBV and HCV and also the association with diabetes mellitus (DM).
Most often the renal involvement consists of membranous nephropathies, membrano-proliferative glomerulonephritis ± cryoglobulinemia, IgA nephropathies, etc.
Of a special interest is the association with DM type II, in fact the diabetic nephropathy in the present work.
The medical literature is currently mentioning several ethiopatogenic links between the viral hepatitis and diabetic nephropathy.
Of a great practical importance, from the nephropathologic point of view is the precise differentiation between all these conditions, which is possible to be fulfilled with the modern laboratory techniques available today.
In this line we are currently performing special techniques for light microscopy, immunofluorescence, and electron microscopy.
The present work emphasizes characteristic features from all these pathologic conditions as well as the most frequent differentiating clues. The main stress will be on the diabetic nephropathy and its association in viral hepatitis, and particular differencing features.
Due to the fact that the diabetic nephropathy occurs in approximately 30 % of the DM type II patients, it is understandable the major interest in this direction as well as a precise diagnosis, and from the point of view of the adequate therapy.
Keywords : HCV, diabetes mellitus, nephropathy, renal biopsy.

(*) This work was supported by CNCSIS -UEFISCSU, project number 1182/2009-ID599 PN II - IDEI code/2008

Authors : Voineag M.1
1 "Victor Babes" Clinic, Bucharest

The adverse effects of antiviral drugs are dose dependent and often reversible. The major side effects include influenza-like symptoms, hematologic abnormalities and neuropsychiatric symptoms.
Ototoxicity is a rare side effect of IFN. 49 studies which include patients with auditory disability have been reported between 1990-2209. Tinnitus and/or hearing loss was found in 43.8 % of this patients and S/N type hearing loss was found in 36.9 % of patients. Most patients recovered 7 - 14 days after the discontinuation of IFN. In these studies, rapid improvement of auditory function after discontinuation of IFN suggests microvascular pathogenesis. Thrombocytopenia induced by IFN might have caused a microvascular accident in the inner ear.
The relation between autoimmunity and hearing loss was also reported in other studies (Kanda, Schultz, Schattner), but the drug (IFN) itself may cause direct toxicity to the auditory nerve hairy cells (Cole).
Keywords : hearing loss, IFN side effect, autoimmunity.

Authors : - Oprisan G.1, Dinu S.1, Ruta S.2, Sultana C.2, Grancea C.2, Alexiu I.2, Manolescu L.2, Anton G.2, Neagu A.2, Sencovici C.2, Calistru P.3, Tardei G.3, Motoc A.3, Lazar St.3, Ionescu C.3, Ceausu E.4, Cristea C.4, Voiculescu Gh.4, Brehar-Cioflec D.5, Popovici E.D.5, Chicin G. 5, Claici C. 5
1 "Cantacuzino" National Institute for Research/Development of Microbiology and Immunology, Bucharest
2 "St. S. Nicolau" Institute of Virology, Bucharest
3 "Victor Babes" Clinic Hospital of Infectious and Tropical Diseases, Bucharest
4 "Carol Davila" University of Medicine and Pharmacy, Bucharest
5 Institute of Public Health, Timisoara

Introduction : Hepatitis C virus (HCV), a major etiological agent of chronic hepatitis with risk of progression to cirrhosis and hepatocellular carcinoma, is classified into six major genotypes and more than 100 subtypes. HCV genotype may influence disease severity and treatment resistance. In Romania there are few data on the distribution of HCV genotypes. Recently, a core+1 protein with unknown function, encoded in alternative reading frame was identified.
The aims of this study were to determine the HCV genotypes circulating in Romania, to identify the presence and the variability of the protein encoded in alternative reading frame and to evaluate tools for epidemiological studies.
Materials and methods : Two hundred and fifty sera from HCV patients, collected within the frame of the CEEX consortium, were analyzed by home-made PCR systems in the core and NS5B regions as well as in HVR1. Sequences obtained in the three genomic regions were analyzed with BioEdit, BLAST and Mega 4 software.
Results : Genotypes distribution in Romania was: 1b - 95%, 1a - 3%, 4a - 1.5% and 3a - 0.5%. All HCV isolates from an outbreak of hepatitis C in Giurgiu County were classified as genotype 1b. An epidemiological link between strains, based on genetic distance, was established. Some epidemic strains presented insertions in the viral envelope region. The presence of genotype 4a might indicate a possible root of circulation from Egypt were this subtype is endemic. All the core sequences obtained from the 300 base pairs amplicon or the entire core region presented an alternative protein reading frame. This shows a much greater variability than the protein encoded in the normal reading frame.
Conclusions : The new PCR systems developed have a good resolving power for HCV subtyping and evaluating transmission routes. The predominant HCV subtype in Romania is 1b, while subtypes 1a, 3a and 4a might have been recently introduced in Romania as a result of drug abuse in the younger population.
Keywords : Hepatitis C Virus, genotyping, core+1, hepatitis C outbreak.

(*) This work was done in CEEX Project 158/2006

Authors : Duiculescu D.1, Ene L.1, Ruta S.2, Tardei G.1, Smith D.3, Mehta S.3, Achim C. 4
1 "Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest
2 "Stefan S. Nicolau" Institute of Virology and "Carol Davila" University of Medicine, Bucharest
3 University of California at San Diego Department of Medicine, La Jolla, California, USA
4 University of California at San Diego, Departments of Pathology and Psychiatry, La Jolla, California, USA

Introduction : The central nervous system (CNS) can function as a virologic compartment for various types of viruses leading to neuradaptation. In this study we investigated the presence and compartimentalization of Hepatitis B Virus (HBV) in the cerebrospinal fluid (CSF) of chronic HIV coinfected patients.
Methods : Paired plasma-CSF samples from 26 HIV/HBV coinfected patients (mean age 17 years, 15 males) with various neurological conditions were retrospectively tested for the presence of HBV DNA using Cobas Amplicor HBV Monitor Test (Roche Diagnostics). We investigated the correlation between CSF and plasma HBV DNA and HIV RNA levels. In a subgroup of 5 patients, we further investigated the presence of HBV antiviral-resistant variants in the CSF and plasma using the reverse hybridization line probe assay (INNO LiPA HBV DR v.2, Innogenetics).
Results : We recovered HBV from the blood of 18 patients (mean DNA 6.01 ± 2.09 log10 IU/ml). Out of these subjects, 11 also had detectable CSF HBV DNA (mean 4.06 ± 1.06 log10 IU/ml). HBV DNA levels were significantly lower in the CSF (p<0.0001), but correlated positively with plasma viral loads (r=0.82, p<0.0001). There was a positive correlation between HBV DNA and HIV RNA levels in both blood plasma and CSF (r=0.59, P=0.001 and r=0.49, P=0.01). Out of 16 patients with an intact BBB, 8 had detectable plasma and 3 of them had detectable CSF HBV DNA levels. Analysis of genetic variation between plasma and CSF HBV, performed in 5 patients demonstrated concordant profiles in 2 cases and genotypic discordance in the other 3. Two of these 3 patients had M204V and L180M mutations detected in both the blood and CSF while having V173L mutation only detectable in blood and A181T mutation only detectable in CSF; the third participant had HBV mutations L180M and A181T only detectable in CSF.
Conclusion : Similar to HIV, HBV can be isolated from the CSF during HIV/HBV chronic coinfection. Correlations between HIV and HBV viral loads in both the CSF and plasma suggest an immunologic relationship between the two viruses. Finally, genetic variation between HBV from plasma and CSF shows evidence of CNS compartmentalization. Further investigations are needed to determine the clinical significance of HBV in CSF.
Keywords : HIV, HBV, central nervous system, compartmentalization.

Authors : Nour A.1, Calistru P.1, Acatrinei E.M.1
1 "Victor Babes" Clinic, Bucharest

Background : Viral hepatitis B (VHB) and C (VHC) infection has a high prevalence in Romania (according to WHO 2007 Statistics data about 2 - 7 % for VHB and 4.9 % for VHC infection), higher than those of European countries.
Purpose : To asses the prevalence of VHB and VHC infection among the patients who presented for medical consult at "Victor Babes" Clinic during a 3-year period.
Methods : A retrospective descriptive study was made by testing 21.778 patients presented in our clinic between January 2006 - December 2008; serum samples were tested for Ag HBs and Anti-HCV by CMIA (chemolumionescent microparticle immunoassay).
Results : 21.778 patients presenting for routine medical workup or for various symptoms (predominately digestive) were tested.
11.167 patients were tested for Ag HBs and 983 were found infected (8.8 %).
10.611 patients were tested for Anti-HCV and 605 were found infected (5.7 %).
Almost all of them were newly diagnosed cases, surprising for both doctor and patient.
Fifty-eight percent were over 50 years (most of them over 65), above the cutoff age for guidelines indication to antiviral therapies.
Several high-risk communities for HBC and HCV infection were identified : medical staff, adult and children healthcare and social assistance providers, previous blood transfusion (for HCV), family members of chronic B hepatitis (casual household contact for HBV), dental and surgical interventions, intravenous drug users, HIV co-infection, nightclub dancers.
Many cases were diagnosed at first medical presentation as advanced-stage B and C infections (cirrhosis or hepatocellular carcinoma), evolving undiagnosed for 20 - 30 years and increasing the risk of interpersonal transmission.
A high prevalence of casual household transmission of VHB infection was also found.
Conclusions : The prevalence of HVB infection is still high, despite the vaccine campaigns and increasing public access to medical information.
HVC infection diagnosis is usually late, above the age limit for therapeutic intervention according to antiviral treatment guidelines.
The mandatory testing for VHB and VHC infections before all interventional medical procedures and the screening of high-risk groups by law becomes imperative.
Keywords : prevalence, infection, VHB, VHC, screening, prevention.

Authors : Carata-Dejoianu T.1, Cernea A-M.1, Constantin M.1
1 "Victor Babes" Clinic, Bucharest

Introduction : Given the increasing number of international travelers, as tourists or with professional goals, there is a rising concern to minimize the risk of illness from infectious diseases; therefore international health organizations (WHO, CDC) recommend certain immunizations before traveling. These recommendations are followed by employing companies, travel agencies, insurance companies, or by patients themselves. Among the most requested immunizations prior to travel, especially to destinations outside Europe, are those for hepatitis A and B.
This paper aims to examine the real need and the benefits of vaccination for viral hepatitis, prior the trip abroad, taking into consideration the prevalence of protective antibodies in the Romanian population.
Materials and methods : We have studied 146 patients presented in DTC "Victor Babes" from March 01, 2008 to February 28, 2010, trying to determine the opportunity of the vaccination for hepatitis A and/or B, when traveling abroad. Of the patients included in the study 40 were women (28 %), and 106 men (72 %). The distribution on age groups was the following : 48 (32.87 %) patients between 15 and 30 years, 68 (46.58 %) patients between 30 and 45 years and 30 (20.55 %) patients over 45 years. The patients have reported no history of acute hepatitis and they did not have any previous vaccination. All of them have requested the vaccination for hepatitis A and B.
Conclusion : Of the total 146 patients :

• 105 (71.91 %) showed protective antibodies to hepatitis A, vaccination being no longer necessary;
• 23 patients (15.75 %) showed protective titers of anti HBs and 5 (3.42 %) showed positive HBs antigen, vaccination is not recommended;
• 16 patients (10.95 %) had antibodies to both VHA and VHB, immunization is not required for either of the viruses.

Given the prevalence of asymptomatic infection with hepatitis virus, the lack of records on previous immunizations, the possible detection of chronic infection with hepatitis B, the vaccination costs versus the cost of serological investigations, the precise determination of serology is necessary before beginning vaccination for hepatitis. Unfortunately the late presentation to the doctor makes this approach difficult.
Keywords : travel, antibodies, hepatitis, vaccination, prevention.

Authors : Acatrinei E.M.1, Calistru P.1, Nour A.1
1 "Victor Babes" Clinic, Bucharest

Background : Cardiovascular disease is a rising global epidemic that is expected to increase. Another global epidemic that appears to increase the risk of cardiovascular disease is chronic hepatitis C virus infection. Numerous recent studies indicate a positive association between hepatitis C virus (HCV) infection and coronary artery disease (CAD) and between HCV core protein and carotid atherosclerosis. Accumulating evidence shows that HCV infected subjects had a significantly higher risk of developing atherosclerotic CAD compared with HCV un-infected subjects, even after the adjustment for traditional risk factors for cardiovascular disease - proving that HCV infection could be an independent risk factor for CVD. The data obtained until present indicates the proatherogenic effects of some viral infections, with cellular and molecular changes that contribute to the pathogenesis of atherosclerosis -knowing that a complex balance between proinflamatory and antiinflamatory cytokines dictates the initiation, propagation and complications of atherosclerosis lesion. The mechanisms responsible for increasing cardiovascular risk in HCV infected patient include a combination of factors like: increased proinflamatory cytokines, increased level of inflamatory markers (high sensitivity C reactive protein, IL6, and tumor necrosis factor alfa), increased oxidative stress, endothelial dysfunction, decreased adiponectin, direct effect of hepatitis C virus on the vessel wall.
We conducted a study to compare the cardiovascular risk factors and prevalence of CAD between HCV infected patient and HCV uninfected control subjects.
Method : We included in study 108 patients : 50 with chronic viral hepatitis C and 58 in control group, evaluated in "Victor Babes" DTC in 2009. The laboratory data included measurements of HCV antibody, total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, triglyceride, hemoglobin, alanine and aspartat aminotransferase, serum albumin, bilirubin, glucose level. Cardiovascular risk factors included : age, male sex, obesity, arterial hypertension, smoke, diabetes mellitus, dyslipidemia. CAD was defined by present of myocardial infarction, positive stress test for myocardial ischemia, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Control subjects were matched by age, sex. We retained only subjects with complete clinical and laboratory data.
Results : HCV infected persons had a lower body mass index compared with HCV uninfected patient.
We obtained an slightly increased prevalence of type 2 diabetes mellitus in HCV-infected subjects but they had a lower prevalence of arterial hypertension, a lower total plasma cholesterol, lower low- density lipoprotein cholesterol and triglyceride levels compared with HCV-uninfected patient. The prevalence of CAD was similar in both groups.
Conclusions : Patient infected with hepatitis C virus had a lower prevalence of traditional risk factors for coronary artery disease, but with all this they associated CAD.
Control of traditional CVD risk factors is crucial for preventing CAD but are insufficient for those with hepatitis C who requiring supplementary measures for cardiac protection. Further studies are need for development of effective prevention and therapeutic interventions to decrease the risk of CVD in HCV population.
Keywords : cardiovascular risk factors, atherosclerosis, coronary artery disease, HCV infection.

Authors : Oprea C.1, Ceausu E.1, Radoi R.1, Tardei G.1, Ungureanu E.1, Erhan R.1, Ionescu C.1, Duiculescu D.1
1 "Victor Babes" Clinical Hospital of Infectious and Tropical Diseases, Bucharest

HIV infection exerts a negative effect on the natural history of chronic hepatitis B and increases the risk of progression to cirrhosis and end stage liver disease (ESLD).
Studies performed in our hospital showed a very high prevalence of HBV infection (41 %) in adolescents with HIV infection acquired by parenteral mode. Out of these, 10% are also coinfected with Delta virus.
The aim of our study was to evaluate the antiviral effect of tenofovir (TDF) in HIV/HBV infected adolescents with previous exposure to lamivudine (3TC).
Methods : Retrospective study in HIV/HBV coinfected adolescents treated with TDF (single or in combination with emtricitabine FTC), admitted in V Babes hospital between January 2008 - March 2010.
We analyzed: HBV and HIV viral loads, CD4 cell count, HBV serological markers at baseline (pre TDF) and after TDF treatment.
Results : We evaluated 34 coinfected patients, all with long previous exposure to 3TC, with a median age of 19 years (range 17 - 21), and who were treated with a TDF containing HAART regimen. Out of these, 20 (58.8 %) were HBe Ag positive, 21 (61.7 %) had detectable B viral loads and 5 (14.7 %) were also coinfected with D virus. HBV viral loads preTDF and after a 6 months (range 3 - 12 months) of TDF treatment were evaluated only in 16 patients. In 12 patients TDF was introduced because of virological failure for both HBV/HIV infections with the selection of M 184V to 3TC, and in 4 because of the high replication of B virus. Even if he mean value of B viral load at baseline was very high (7,72log10), there was an important reduction of 4 log10 after 6 months of treatment in the majority of cases (15/16) in the context of a good control of HIV infection.
Conclusions : TDF treatment (single or in combination with FTC/3TC) was efficient in suppression of HBV replication in adolescents with long previous exposure to 3TC.
Keywords : Tenofovir, HIV/HBV, adolescents.

Authors : Streba C.T.1, Vere C.C.1, Nita-Stefanescu L.1, Salan E.1, Ionescu A.G.1, Tapu F.1
1 Department of Internal Medicine, Emergency County Hospital, Craiova, University of Medicine and Pharmacy of Craiova

Hepatocellular carcinoma (HCC) is the fifth cancer worldwide. HCC is usually associated with liver cirrhosis of various etiologies and viral hepatitis. We analyzed the associations between HCC and comorbidities and their relations with various environmental parameters in a lot of patients.
We studied the characteristics of a group of 244 patients diagnosed with HCC admitted between January 2006 and October 2009 in the Emergency County Hospital of Craiova. The diagnosis of HCC was based on internationally accepted histologic criteria. The diagnostic of LC was based on clinical, biologic, endoscopic and ultrasonographic criteria. HBsAg(+) or anti-HCV(+) without LC signs were used as markers for non-cirrhotic HCC patients. We used descriptive statistics and Student's T-test for data analysis.
The study group consisted of 148 males and 96 females. LC was also present in 84 % of the study lot, 10 % associated viral B hepatitis (HBV) and 6 % viral C hepatitis (HCV), with no signs of LC. The mean age of the LC subgroup was 69 ± 7 years, for HBV 61 ± 6 and 64 ± 9 for HCV respectively. We noticed a strong correlation (p<0.001) between the rural environment and the association with LC. HVB was also more present in patients coming from rural areas (p<0.01). Alcohol intake was present in 89 % of the whole lot, being more correlated with the presence of LC (p<0.01).
Cirrhosis proved to be the primary risk factors for HCC. We underline the fact that HCC was found to be directly associated with viral hepatitis, without evident LC. We believe that further studies are needed in order to establish if intensified HCC screening, especially in rural areas, is required in patients with newly diagnosed viral hepatitis. The increased prevalence of HBV infections might encourage HBV vaccinations as an efficient tool to prevent HCC.
Keywords : hepatocellular carcinoma, cirrhosis, chronic viral hepatitis.

Authors : Vere C.C.1, Streba C.T.1, Ionescu A.G.1, Salan E.1, Nita-Stefanescu L.1, Tapu F.1
1 Department of Internal Medicine, Emergency County Hospital, Craiova, University of Medicine and Pharmacy of Craiova

Patients with chronic liver affections can be predisposed to diabetes due to autoimmune mechanisms caused by the primary affect, or by therapy. Infection with virus C hepatitis (HCV) seems to be a primary factor associated with diabetes. Our aim was to verify the possible direct correlation between HCV, pegylated inteferon (Peg-IFN) therapy and insulin necessary in diabetic patients.
We conducted a retrospective study to determine the prevalence of diabetes in a group of HCV patients who underwent treatment with Peg-IFN and ribavirin. Our study lot was composed of 134 patients admitted in the Emergency County Hospital of Craiova, between January 2006 and December 2008. We assessed the necessary of insulin in diabetes mellitus patients. Our study lot included 66 males and 68 females, with a median age of 56 years, minimum being 37 and maximum 72. In the total lot, diabetes mellitus was found in 28 % of the subjects. We found a positive association between old age (quartiles 4 - 50 to 60 years and 5 - 61 and above years, p<0.001) and the incidence of diabetes. We also found a slightly increased necessary of insulin after 12 months of Peg-IFN therapy in both male and female subjects (p<0.05), which proves that antiviral treatment interferes with the course of the diabetes. We found the insulin necessary to be higher in older subjects.
Diabetes mellitus might appear due to the direct action HCV, or by autoimmune mechanisms on the pancreatic B cells. Peg-IFN treatment might favor, in genetically predisposed subjects, the expression of the major histocompatibility complex antigens at a pancreatic cellular level. Following an insulin-dependent autoimmune process, the antiviral therapy might aggravate the morphofunctional dysfunction in the pancreas.
Keywords : chronic hepatitis C, peginterferon, insulin-dependent diabetes mellitus.

Authors : Nita-Stefanescu L.1, Vere C.C.1, Streba C.T.1, Ionescu A.G.1, Salan E.1, Tapu F.1
1 Department of Internal Medicine, Emergency County Hospital, Craiova, University of Medicine and Pharmacy of Craiova

Extrahepatic determinations in patients with hepatitis C have a special importance because they are responsible for most of relapses of infection, thus affecting the quality and life expectancy of patients.
Our aim was to study the incidence of extrahepatic manifestations in a lot of patients with chronic hepatitis C virus (HCV) infection.
We conducted a retrospective study on a sample of 48 patients with HCV infection admitted in the Emergency County Hospital of Craiova, treated with interferon alfa-2B, 3000000 IU x 3 times/week, for 12 months. We monitored their liver function, along with regular urinalysis, renal ultrasound, thyroid scintigraphy, hormonal determination where needed (T3, T4, and TSH), dermatological examination and determination of cryoglobulins.
The study group included 17 men (35.41 %) and 31 women (64.58 %), with a mean age of 54.51 ± 10.45 years. We found extrahepatic manifestations in 29 cases (60.41 %): diabetes mellitus 10 cases (20.83 %) - 6 cases with type 1 and 4 cases with type 2 diabetes, vascular purpura 4 cases (8.33 %), 4 arthritis cases (8.33 %), Raynaud's syndrome 3 cases (6.25 %); thyroid manifestations 4 cases (8.33 %), 2 cases of renal disease (4.16 %) and late cutaneous porphyria 2 cases (4.16 %). We found 22 cases (45.83 %) with mixed cryoglobulinemia, 11 of them being asymptomatic. During interferon therapy we recorded hyperglicemia in 6 cases, 3 cases with insulin-dependent diabetes mellitus and 3 cases with type 2 diabetes. Vascular purpura persisted after treatment in 3 cases (6.25 %), therapy with interferon favorably influencing most extrahepatic determinations.
Mixed cryoglobulinemia has an increased frequency in HCV infection, but some cases are asymptomatic. During interferon therapy a higher dose of insulin was necessary in patients with insulin-dependent diabetes mellitus. Interferon therapy has a favorable effect on extrahepatic lesions of HCV infection, but post-therapy relapses can occur.
Keywords : Extrahepatic manifestations, chronic hepatitis C, peginterferon.

Authors : Popescu A.1, Udrescu M.1, Cristea C.1, Chivu C.1, Oprea O.1, Nicolau A.1, Andreescu I.1, Greceanu I.1
1 "Medicover" Clinic, Bucharest

In Medicover clinic was done a non-randomized retrospective study over a period of one year: a cohort of asymptomatic patients without known hepatic disease were tested for ALT.
The study investigated the incidence of chronic viral hepatitis vs. other etiologies of hepatic cytolysis: alcoholic or nonalcoholic steatohepatitis and nonviral liver cirrhosis.
We analyzed 5826 electronic files of asymptomatic patients. In 537 patients with hepatic cytolysis, indicators such as sex, age, body mass index, waist circumference, metabolic syndrome X, anamnestic data (alcohol), abdominal ultrasound data (fatty liver and portal hypertension) and viral hepatitis markers were determined.
Results: Among the 5826 patients screened, 537 (9.21 %) patients had hepatic cytolysis (89% men and 11% women), of which 80% had low transaminase values, below 2 times normal value (2xN). 91% of patients with hepatic cytolysis were under 50 years and 41% of them were overweight. 13 % of patients with values >2xN reported drinking daily, comparing with 5% in those with transaminase values <2xN. Testing for viral markers detected hepatitis B in 13 patients and hepatitis C in 9 patients. ALT value was not a predictive factor for chronic viral hepatitis.
The determination of viral markers in asymptomatic individuals with increased ALT allowed proper diagnosis and treatment of few new cases of chronic viral hepatitis in asymptomatic patients (0.37 %) and questioned the cost-effectiveness of annual screening with ALT. Instead we found a large number of alcoholic and nonalcoholic steatohepatitis, diseases in which lifestyle changes can determine a favorable long-term outcome.
Keywords : hepatic cytolysis, chronic viral hepatitis, screening.

Authors : Constantin M.1, Cernea A-M.1, Carata-Dejoianu T.2, Cimpoesu (Lupu) I.1
1 "Victor Babes" Clinic, Family Medicine Department, Bucharest
2 "Victor Babes" Clinic, Epidemiology Department, Bucharest

Background : In Romania, the prevalence of virus hepatitis B, C infection is about 2 - 7 % for hepatitis B and 4,9 % for hepatitis C. Health care workers exposed to blood and those who take care of people with disabilities have a high risk to be infected.br /> Purpose : To asses the prevalence of virus hepatitis B and virus hepatitis C infection among health care providers from adult and children health care and social assistance centers.br /> Methods : 161 health care providers from 15 adult and children health care and social assistance centers were investigated for hepatitis B and hepatitis C infection between June 2009 - March 2010. All health care providers were employed before 2008. Serum samples were tested for AgHBs and Anti-HCV by CMIA (chemoluminescent microparticle immunoassay).
Results : 161 health care providers were investigated (148 women, 13 men); average age was 41. They were represented by : physicians (8), physician assistance (36), nurses (109), social workers (2), other care workers (6). 8.07 % were infected with hepatitis B, C viruses (13 people); 3.72 % were AgHBs positive (6 persons) and 4.34 % were Anti-HCV positive (7 persons). For two centers (specialized in taking care of homeless and handicapped persons), the number of positive cases was higher (4, respectively 5 cases).br /> All positive cases were diagnosed at nurses (13 infected people) and they were newly-diagnosed cases (except one of them). Risk factors for hepatitis B, C infection were identified for four cases (they had surgical interventions).br /> Conclusions : In our study 8.07% of tested people were positive for hepatitis B or C viruses. Prevalence of virus hepatitis B infection was 3.72 % and 4.34 % for virus hepatitis C infection. Centers specialized in taking care of homeless and handicapped persons were identified with higher number of positive cases. An increase number of newly-diagnosed cases were registered. All infected health care providers were nurses.br /> In conclusion, we consider very important to test all health care providers newly-employed for hepatitis B and C, inform them about the modes of transmission for viral hepatitis B, C and about universal precaution rules. Epidemiological investigations are neccessary for infected people.
Keywords : prevalence, hepatitis B, hepatitis C, healthcare providers

Authors : Dinu S.1, Oprisan G. 1
1 "Cantacuzino" National Institute for Research and Development in Microbiology and Immunology, Bucharest

Introduction : Chronic infection with hepatitis C virus (HCV) can lead to cirrhosis and hepatocellular carcinoma. The current therapy used in HCV infection (pegylated interferon associated with ribavirin) is not efficient in all cases (especially in patients infected with genotype 1b) due to mutations occurrence and also to the lower treatment response. The HCV capsid core protein is involved in carcinogenesis. Specific mutations associated with treatment resistance and hepatocarcinoma were identified.
Aims : The aims of this study were the design and optimization of some ARMS PCR ("amplification refractory mutation system polymerase chain reaction") used to detect interferon/ribavirin resistance mutations in HCV core protein (R70Q(H) and L91M).
Material and method : Two hundred forty five core sequences from 1b genotype isolates were analyzed in order to design mutation specific primers. Thirty one of these sequences were obtained from Romanian isolates using an original RT-PCR system capable to amplify a large number of genotypes.
Results : Following the sequence analysis, 12 primers able to detect the two mutations were designed. Six PCR systems were optimized: the first two are used to detect L91M mutation by generating a 235 bp amplicon, systems 3 and 4 detect R70Q(H) mutation by amplification of a 172 bp fragment. The other two systems are controls for the reactions 1, 2 respectively 3, 4. The results obtained from optimization of reaction show that for the specificity it was necessary to use low concentrations of primers and dideoxynucleoside triphosphates (100nM respectively 100µM), a "hot-start" DNA polymerase and high annealing temperatures (71° respectively 72°C) in order to prevent non specific amplification.
Conclusions : The newly developed systems differentiate between wild type and mutated viral variants induced by the interferon and ribavirin treatment. The implementation of these ARMS PCR systems may be useful in the evaluation of treatment efficiency and HCV infection evolution. Evaluation of a quantitative real-time PCR using the primers developed in the present work can also help to study the dynamics of emerging resistant viral variants.
Keywords : hepatitis C virus, genotype 1b, treatment resistance mutations, interferon, ribavirin, ARMS PCR.

Authors : Arbune M.1
1 "Sf. Cuvioasa Parascheva" Infectious Disease Hospital, Galati

Objectives : To assess the prevalence of HIV/HBV coinfection and the impact on HIV outcomes among the youth under antiretroviral treatment (ARVT).
Material and methods : Prospective open study (2004-2009) was based on 168 participants born between 1990-1988 horizontally HIV infected during early childhood. Clinical exam, HBV surface antigen (HBsAg), ALAT, CD4 count, HIV viral load were analyzed every 6 months.
Results : Baseline HBsAg+ was found on 43 % of 168 patients: 10 were censored, 15 died and 143 survived. Characteristics of the 168 participants: M/F: 75/93; clinical HIV stage B/C : 54/104; median nadir CD4 127.5/mm3 [4; 857]. Positivity rate of HBsAg changed from 66/92 to 53/105 because of 13 seroconversions (19.6 %) and 2 new infections with HBV. Elevated ALT were found on 41 % but only 12% (9) > x 5 normal values and 5.7 % (8) persistent hepatocytolisis > 6 months. 97.5 % of the patients experienced median 47 months of Lamivudine during the study and summarized a median 3 [1; 8] ARV combinations until the end point. CD4 count increase, detectable HIV and surviving rates were similar on coinfected HIV/VHB and HIV-only patients. ALT elevation is correlated with HIV/HBV coinfection (p<0,001; OR 5.05; 95 % CI 2.48-10.27) and male sex (p<0.001; OR 2.12; 95 % CI 1.05-4.26).
Conclusions : 1. Prevalence of HIV/HBV coinfection is 43 % on Romanian adolescents with nonvertically pediatric infection.
2. HIV/HBV coinfection is related to higher risk of hepatocytolisis, but not to HIV outcomes following ARVT.
3. Extensive use of Lamivudine for ARVT allows HBV resistance development.
Keywords : coinfection VHB-HIV, the youth.

Authors : Acatrinei E.M.1, Nour A.1
1 "Victor Babes" Clinic, Bucharest

Multiple alterations of hemostasis are characteristic of chronic liver disease and the treatment and prophylaxies of this disorders influence much of medical decision making in cirrhosis patient. It is well known the disruption in the balance of procoagulant proteins such as tissue factor, factor VII, factor X and von Willebrand factor compared with the rate of breakdown of innate anticoagulants molecules such as Protein C, Protein S and antithrombin. It is imbalance in the complex interaction between production and degradation pathways-decreased synthesis of blood coagulation factor and their inhibitors, increased fibrinolytic activity, evidence of intravascular coagulation.
All that leads to dysfunction of hemostasis and clinically evident disturbances in both bleeding and clotting in cirrhosis patient. Another important concept is the key role of the platelet. The development of thrombocytopenia in patient with chronic liver disease HCV is complex and multifactorial. Mild to moderate thrombocytopenia is seen in about in approximately one third of patient with chronic liver disease as a result of hypersplenism secondary to portal hypertension, bone marrow suppression resulting from either HCV itself or interferon treatment, aberration of antiplatelet antibody and/or immune complex that binds to platelet and facilitate their premature clearance, development of immunologically mediated extrahepatic manifestations including cryoglobulinemia and trombopoietin deficiency secondary to liver dysfunction. Abnormal platelet function tests include reduced platelet adhesion, abnormal platelet aggregation to ADP, epinephrine, thrombin. Regarding the role of hepatitis C virus in thrombocytopenia, there is a strong association of hepatitis C virus infection and thrombocytopenia, which is related with hepatocellular damage and hepatic fibrosis; the prevalence of thrombocytopenia among antiHCV positive subjects increased as the severity of liver diseases increased and thrombocytopenia seems to be reversal after treatment with IFN alfa monotherapy and this reversal is concomitant to improvement in biological and virologic HCV markers.
We present a case of a patient, 55 years old who associate two conditions: liver cirrhosis with hepatitis C virus B stage Child-Pugh and severe ischemic disease that needs cardiac surgery (CABG) - both of them implicate multiple alterations of hemostasis and potential for life-threatening complication.
It has been well documented the hemostatic abnormalities in patient undergoing cardiac surgery, which include : coagulation factor deficiencies, increased fibrinolytic activities, disseminated intravascular coagulation, inadequate heparin neutralization, thrombocytopenia and platelets defects. It has been suggested that platelet activation and platelet dysfunction account for majority of hemostatic alteration seen during the procedure. Platelet concentrates are administrated to stop bleeding and antiplatelet drugs are used to control platelet activation during the procedure.
We also know that traditional measures of coagulation are often not helpful in bleeding and clotting risk in cirrhosis patient and may be mislead. Other diagnostic tests are clearly needed to accurate assess hemostasis in these patient. The new generation of assay should incorporate global tests of the clotting system rather then being quantitative measures of protein level or cell counts. For example, TEG tromboelastogram, the ELT euglobulin lysis time and perhaps genetic markers - are needed to help the clinician make decision on important clinical questions such as bleeding prophylaxies prior to procedures, risk therapy for the actually bleeding patient, bleeding and clotting disease in this patient. In conclusion, new development of prophylactic and therapeutic interventions is needed to help the clinical management in this patient.
Keywords : thrombocytopenia; hemostatic abnormalities; hepatitis C virus infection.

Authors : Calomfirescu C.1, Ceausu E.1, Calistru P.1, Motoc A.1, Culinescu A.1, Mindru N.1, Ionescu C.1
1 "Victor Babes" Clinical Hospital for Tropical and Infectious Diseases, Bucharest

Romania is a country with a high incidence of Hepatitis B (over 8%) and the main way of transmission is perinatal. The vertical transmission of the C virus is of lower incidence.
Method : Retrospective study on 108 pregnant women with chronic hepatitis B, B+D and C, followed between 01.01.2009-01.04.2010 in the Hepatology Center of the Dr. Victor Babes" Clinical Hospital for Tropical and Infectious Diseases.
Results : The number of pregnant women with Viral Hepatitis B is high (99 cases), whereas B+D (5 cases) and Chronic Hepatitis C (4 cases). The majority of pregnant women were diagnosed during pregnancy (89 case). ALT value during pregnancy varied between normal and 4 times the upper normal limit. The value of ADN-VHB test, on 40 cases, was done in the 28th week of pregnancy, varied between normal and 68000000 IU. All newborns received passive immunization with Hepatitis B Immunoglobulin followed by Engerix vaccination in the first 24 hours. A number of 24 children tested for Ag HBs had negative results. 75% of cases with Viral Hepatitis C had positive HCV ARN. A number of 2 children from these mothers are anti-VHC positive. During pregnancy and after delivery 4 pregnant women had an agravated status. 2 of these women developed hepatic cirrhosis (HBV+HDV).
Conclusions : Testing for hepatitic viruses and viral markers is mandatory during pregnancy. The immunization of newborn reduced the transmission of hepatitis B. Pregnancy is an immunodepression factor for pregnant women with chronic hepatitis.
Keywords : perinatal transmision, ADN-VHB, pasive and active immunization.

Authors : Iacob S.A.1, Banica D.2, Panaitescu E.3, Cojocaru M. 4, Iacob D.G.5
1 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Department of Infectious Diseases
2 "Marius Nasta" National Insitute of Pneumonlogy, Bucharest, Department of Molecular Genetics
3 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Department, Department of Biostatistics
4 Faculty of Medicine and Dental Medicine- Immunology Department
5 "Carol Davila" University of Medicine and Pharmacy, Bucharest, student

Introduction : Human cathelicidine LL37 is a key molecule of the Immune System, regulated by vitamin D. LL37 exhibits a wide antimicrobial spectrum as well as an immune modulating activity. LL37 interferes with virus invasion, replication and removal of infected cells, acting both through a direct mechanism and indirectly by modulating Th1 cell response. The action of LL37 against hepatitis viruses has not been previously studied. The aim of our study was to asses the plasma variations of LL37, in hepatitis viral infections.
Material and methods : The study was performed on 87 subjects hospitalized at Matei Bals Institute between January 2009 and September 2009: 65 patients diagnosed with viral hepatitis of different etiologies and 22 controls. Plasma levels of LL37 and 25(OH)D were assessed with Elisa. The immune response was also evaluated (IFN-? plasma level and CD4/CD8 ratio). LL37 plasma concentration was correlated with the vitamin D status and the immune status for all patients with hepatitis as well as for groups with hepatitis of different etiology and groups with different viral load (active versus inactive hepatitis).
Results : The level of LL37 and IFN-? was increased in all patients with hepatitis versus controls (p=0.045, p=0.0059 respectively). CD4 level was increased only in patients with active hepatitis (p=0.02). Patients with active hepatitis C presented a significant raise of LL37 (p=0.01), IFN-? (p=0.01) and CD4/CD8 ratio (p=0.004). Inactive hepatitis B patients displayed also increased LL37 concentrations (p=0.009). All subjects exhibited a severe deficiency of 25 (OH)D (<54 nmol/L).
Conclusions : Plasma variations of LL37 and its correlations with 25(OH)D level and with the cellular Th1 immune response prove its complex role in all types of viral hepatitis infections.
Keywords : cathelicidine LL37, hepatitis.

(*) This work was supported by CNCSIS - UEFISCSU, PNII-Idei, code 1165/2008.

Authors : Cretu A.M.1, Aschie M.2, Preda G.1, Rosoiu N.3
1 Ovidius University of Constanta, Faculty of Natural and Agricultural Sciences Department of Biochemistry, Emergency Clinical Hospital of Constanta
2 Ovidius University of Constanta, Faculty of Medicine, Emergency Clinical Hospital of Constanta
3 Ovidius University of Constanta, Faculty of Medicine, Full Member of Romanian Academy of Scientists

The definite diagnosis of malignant effusion is often complicated by the presence of inflammation, exuberant mesothelial hyperplasia and a paucity of malignant cells. Cytologic examination alone, provide only limited sensitivity for the detection of metastatic carcinoma cells in many cases of serous effusions.
Current study was aimed to differentiate peritoneal effusions encountered in 81 available cases on various biochemical criteria and also we have examined the mesothelial cells from routine morphometric features. The cases were admitted between September 2007 and January 2010 in the Emergency County Hospital of Constanta and were chosen to show both patterns, benign and malignant, and in this way to achieve a diagnostic value of this methods.
Cytologically, 41 (50.61 %) peritoneal fluids smears were classified as benign (negative cytology), 33 (40.74%) were malignant (positive cytology) and 7 (8.64 %) were considered suspicious for malignancies. The various cellular parameters that were measured by cytomorphometry included nuclear as well as cytoplasmic diameter, area, ratio of nucleus to cytoplasmic area. For biochemistry evaluation were used 17 parameters: total proteins, albumin, lactate dehydrogenase, total cholesterol, glucose, total lipids, tryglycerides, alpha amylase, alkaline phosphatase, urea, total bilirubin, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, magnesium, iron and potassium, determined from the resulted supernatant after centrifugation in blood and peritoneal fluid.
Thus, of all measured parameters, the highest accuracy in the differential diagnosis between malignant and the benign cases (cirrhosis) was obtained by measuring peritoneal effusions total cholesterol (90 %), peritoneal fluid lactate dehydrogenase (85.36 %) and serum-effusion albumin gradient (85 %).
Cytomorphometry helped in a better and quicker sorting for malignant cells. Finally, 42 (51.85 %) cases were found to be benign, 36 (44.44 %) malignant and 3 (3.70 %) in the category of atypical cases with uncertain diagnostic.
It is concluded that computerized image analysis can rapidly digitize the image of the cells and thereby can estimate various morphometric parameters of the cell, and can also be correlate with biochemical analysis of peritoneal effusions.
Keywords : biochemistry, cytomorphometry, peritoneal effusions, benign, malign.

Authors : Voineag M.1
1 "Victor Babes" Clinic, Bucharest

Otitis media is one of the most common infectious diseases of infancy; a reduction in its incidence would have a significant economic and social impact. Streptococcus pneumoniae causes about 50% of RAOMs.Vaccines may play a role in the prevention of otitis media. We reviewed the literature for results of studies examining the role of vaccines against pneumococci in the prevention of otitis media.
The 23-valent polysaccharide anti-pneumococcal vaccine (Pneumo23) did not modify the incidence of otitis media in children aged 2 years less, the age group with the highest incidence of otitis. Over age 2 years, the efficacy of this vaccine in preventing invasive pneumococcal disease is 56 to 81%. Efficacy has not been demonstrated - even in immuno-competent individuals - in the prevention of disease that course without bacteremia, such as otitis media.
The heptavalent anti-pneumococcal vaccine (Prevenar) did not significantly reduce the incidence of otitis media overall, but it reduced the number of episodes of otitis media with effusion and the number of recurrences. It also alters the microbiological profile of RAOM; there is a lower incidence of antibiotic-resistant pneumococcal serum types. Otolaryngologists must be aware of potential role of these vaccines and impact in the reduction of recurrence of otitis media.
Keywords : otitis media, Streptococcus Pneumoniae, Pneumo23, Prevenar.

Authors : Voineag M.1
1 "Victor Babes" Clinic, Bucharest

Human immunodeficiency virus (HIV) infection, which is responsible for AIDS, is one of the most widespread in the world. Its clinical manifestations are polymorphous, and are caused by the virus itself (primary lesions) or the resulting immunodepression (secondary lesions). All the body can be affected, and the ENT organs are frequently involved. About 80% of patients with HIV infections present with otolaryngological symptoms. Often, the otolaryngologist is the primary physician who diagnoses the HIV infection.
The aim of our review was to determine the overall incidence of otolaryngological manifestations, the clinical presentations, relevant diagnostic tools, management, and survival rates.
Oropharyngeal findings, which were the commonest, were seen in 59%, followed by cervical lymphadenopathy in 42% of patients. Oral candidiasis was the commonest oropharyngeal finding, seen in 39% of patients. Among nasal complaints, rhinosinusitis was the commonest, found in 17% of patients. Otological manifestations were seen in 20%, of which chronic suppurative otitis media was the commonest, seen in 13% of patients.
With the increase in the number of AIDS cases, it is important for otolaryngologists to be aware of otolaryngological manifestations. Early diagnosis and timely intervention along with appropriate antiretroviral therapy improve survival rates.
Keywords : HIV infection, candidiasis, lymphadenopathy, rhinosinusitis.

Authors : Stefanescu C.1
1 "Victor Babes" Clinic, Bucharest

The indications for colposcopy have changed recently because of the new Bethesda terminology, and because of the introduction of HPV testing in clinical practice, and the latest consensus guidelines on management of patients with an abnormal cervical cytological test.
Colposcopy remains the reference technique to assess patients with abnormal test results, especially with ASC-H, L-SIL, H-SIL, AGC. In patients with an ASCUS test result, colposcopic examination of only those with test positive for high-risk HPV, increases the specificity of the technique.
In primary screening using both cytology and HPV DNA testing in patients over the age of 30, colposcopy is indicated when normal cytology, but two high-risk HPV ADN positive tests performed at a 9-12 month interval.
For the follow up of abnormal cytological tests,colposcopy after positive HPV at 12 month is as sensitive as colposcopy after at least two abnormal cytological tests, at 6-12 month.
After treatment (excision or conization) in patients with low-grade CIN, colposcopy after a single high-risk HPV ADN positive test at 12 month is as sensitive as cytology and colposcopy at 6 - 12 months.
After treatment (excision or conization) in patients with high-grade CIN,colposcopy after a single high-risk HPV AND positive test at 6 month is more sensitive as cytology and colposcopy at 6 month.
Keywords : colposcopy, HPV test, abnormal cytological tests.

Authors : Apostol I.1, Comsa F.1
1 "Victor Babes" Clinic, Bucharest

Background : The idea that vaccines may have nonspecific effects was first mentioned in 1991, in Senegal, Africa. We are wandering: Can antiflu and antipneumoccocal dual vaccination have nonspecific effects ? The study of nonspecific postvaccinal effects on different immunesenescence parameters can be useful in mortality risk evaluation in the elderly. The objective: the study of postvaccinal appearance of changes compatible with immunologic risk profile (low CD4, high CD8, CD4/CD8 subunitar, high total IgG and IgA) and chronic inflammatory status (high CPR, TNFα and IL6).
Material and method : Two years prospective study, on elderly subjects, vaccinated with Vaxigrip and Pneumovax and monitored at the moments-prevaccinal L0 and postvaccinal: L1-early; L3-intermediar; L12-belated. There were tested vaccination effects on parameters: CD4, CD8, CD4/CD8 ratio, total IgG, IgA, TNF, IL6 and CRP. For specific laboratory tests we have used: lymphocites immunophenotyping (FacsCalibur-Becton Dickinson), chemiluminescence (Immulite-DPC), nephelometry (BN ProSpec-Dade Behring). Statistical analysis: ANOVA testing and data processing using software MiniTab 15.
Results : On the following parameters: CD8, CD4/CD8 ratio, IgA, CRP, TNFα we have not obtained nonspecific postvaccinal effects. Instead, we have recorded three possible detrimental nonspecific effects : lowering CD4, increasing total serum IgG and increasing IL6.
Conclusions : Two of the nonspecific effects (low CD4, high IL6) were not found to be statistically significant by ANOVA, but we have confirmed an nonspecific effect of increasing total IgG. Postvaccinal increasing of total IgG can be related on specific IgG increasing but in the lack of studies based on IgG subclasses determination we can state that dual vaccination was associated with a possible detrimental effect on immune status. The studies on elderly vaccination are quite new and open new research directions regarding effects of aging on the immune system and ways for more efficient elderly vaccines.
Keywords : vaccination, nonspecific effects, immunesenescence, immune risk profile, chronic inflammation.

Authors : Comsa F.1, Bumbac A.1, Paunescu V.1
1 "Victor Babes" Clinic, Bucharest

Background : One day surgery advantages for patients with varicose vein.
Material and methods : Analysis of 1680 patients with varicose vein undergoing surgery between years 2005 and 2010 in "Victor Babes" Clinic.
Pre-operatory ultrasound examination (150, 8.92%) highlights varicose veins, dilated and incompetent perforators, venous reflux quantification and preoperative venous mapping. High sapheno-femural junction (1244, 74.04%) and all tributaries ligation (1531, 91.13%), phlebectomy, preoperative marked perforating veins ligation (150, 8.92%) were performed with histological examination of veins fragments. We used Clinical, Etiological, Anatomic, Pathophysiologic classification (CEAP).
Results : Within the studied group (F=1086, M=594), with mean age of 51.35 (minimum 17, maximum 88), number of elderly patients and advanced stages was increased (63 years, 13 % yearly). The increased number of patients in incipient, uncomplicated stages (52.3%) proves the effect of medical education. Cases with superficial thrombophlebitis (116, 6.9 %), stasis pigmentation (421, 25.05 %), active ulcer (221, 13.15 %) were constant through the entire period. Microscopic examination highlights segmental thickness of intima and media, endothelial cell activation and increased quantity of extracellular matrix in intima and media, more distal the vein is more emphasized changes are.
Conclusions : Ambulatory surgical procedure, performed under local anesthesia, with small incisions (5 - 7 mm), in skin plies, minimum bleeding and early post surgery mobilization avoid complications risk. Immediate social and family integration realize a better influence on patient mental status; costs are kept low and recurrence is minim (1.7 % at 3 years-ultrasound established). Venous parietal changes are due to hemodynamic stress, thick areas alternating with normal ones.
Keywords : chronic venous insufficiency, venous ultrasound mapping, perforants surgery, one day surgery.

Authors : Dr. Nour A.1, Acatrinei E.M.1
1 "Victor Babes" Clinic, Bucharest

The 2007 Updated European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines has underlined the importance of contrast-enhanced abdominal ultrasound (CEUS) for the detection and characterization of focal liver lesions. Contrast agents represent suspensions of air or gas "microbubbles" stabilized within a "shell" of lipid or albumin with a particular intravascular disposition (allowing free capillary passage but limiting the distribution to the vascular compartment). Contrast agents used in abdominal ultrasound can differentiate benign liver lesions (regenerative nodules, focal nodular hyperplasia, hemangioma) from malign lesions (hepatocellular carcinoma, liver metastasis), based on their particular pattern, according to liver vascularisation.
Three imaging phases have been defined during CEUS on the basis of the liver's particular hemodynamics (dual blood supply, from both the hepatic artery and the portal vein):

• arterial phase - early in 15-30 seconds
• portal venous phase - in 45-120 seconds after intravenous injection of contrast agent
• late phase (washout) - up to several minutes

The effect is based on sustained enhancement/hypoenhanced lesions compared with normal liver parenchyma. The most important advantage of CEUS is the opportunity to do continuous real-time imaging, with the possibility to make video recordings which can be reevaluated later with a dedicated ultrasound machine.
CEUS is considered equivalent to contrast computed tomography (CT ) in terms of sensitivity for the detection of metastases and hepatocellular carcinoma. This method has many advantages: lack of radiation exposure, safe contrast agents with very rare side effects (allergic reactions - less than 0.01%), no kidney toxicity or iodine structure to impair thyroid function, noninvasive nature, greater cost-effectiveness in comparison with other imaging techniques (CT, MRI) and superior availability, applicable also at bedside.
CEUS represents an important diagnostic tool in focal liver lesions, increasing the specificity and sensibility of the diagnosis and, probably will become the imaging method to guide and follow the percutaneous ablative procedures.
Keywords : liver, echocardiography, contrast, microbubbles.

Authors : Tardei G.1, Ceausu E.1, Cristea C.1, Oprea C.1, Popa I.1
1 "Victor Babes" Clinical Hospital of Infectious and Tropical Diseases, Bucharest

Introduction : Influenza virus infection in humans evolves to disease only in a small proportion of subjects, depending on multiple factors among which the immune status prevails. Local and systemic cellular immunity are crucial for successful immune response against viruses, including influenza. Clinical laboratory evaluation of cellular immunity has little standardization except for HIV infection. In the present study we aimed to dynamically evaluate the cellular immunity of influenza patients during the epidemic season, by counting CD4 and CD8 T lymphocytes in the peripheral blood.
Material and method : Twelve adult non-HIV patients with influenza were tested during January - February 2010 and two months later. Two patients with secondary immunosupression were also investigated, one being HIV infected and the other being treated with chemotherapy and anti-CD20 monoclonal antibodies. Cellular immunity was evaluated by flow-cytometric immunophenotyping of CD4 and CD8 T lymphocytes in the peripheral blood, using a FACSCalibur flow-cytometer and CD3, C4, CD8 monoclonal antibodies for in vitro diagnostic from Becton Dickinson.
Results : Non-HIV patients showed no significant change of T lymphocyte percentages, neither compared to normal ranges nor compared with each subject's values observed when fully recovered from influenza. All lymphocyte counts were minimally reduced during influenza compared to the healthy state, while CD4/CD8 ratio remained within normal ranges in the two dynamic evaluations. In the two immunosupresed patients selective TCD4 lymphopenia and decreased CD4/CD8 ratio were noted during the epidemic season, showing no clinical symptoms of influenza but developing pulmonary complications. The HIV patient tested positive for the novel H1N1 influenza in serological evaluation at the time of pulmonary complication.
Conclusions : Our observations in this small group, and other authors in the literature, show that systemic, peripheral blood cellular immunity assessment has minor relevance in subjects with normal immune system. In contrary, counts, percentages and ratio of CD4 and CD8 T lymphocytes are significantly affected by influenza infection in patients with pre-existing immunodeficiency. Common cellular immunity evaluation tests in the peripheral blood do not always witness for the immunodeficiency secondary to influenza, which often results in bacterial super-infections, mostly of the lungs.
Keywords : cellular immunity, influenza, immunodeficiency.

Authors : Matei G. I.1
1 "Victor Babes" Clinic, Bucharest

Introduction : Primary cancers and leukemia treated in 1980th decade generate in present a raised number of secondary cancers. Risk of secondary cancer after radiotherapy is significant. The research of medical databases indicates a scarcity of clinical studies and revisions regarding secondary cancers. Secondary cancers are difficult to differentiate from the novo recurrent tumors.
Material and methods : references identification for the clinical care in medical databases Pubmed-Medline and Up to Date. The patient's medical file served as an information resource for clinical case presentation.
Results : Difficulties of care in case of terminal patients with secondary cancers is a consequence of curative limits of treatment. In majority of cases treatments proposed, after their risks presentation, have palliative intention. The age of the patients varies in media between 45-55 years, with all social and familial implications.
The body image is profoundly alterated in case of stoma and urostoma patients. Neither personal care of stoma do not guarantee the acceptance of the own body transformations, and self acceptation. Hastening death by refusing active eating, antibiotics or chemotherapy treatments has profound implication over patient, and especially over the family and members of the team caring the patient. This aspect could expres indirectly profound communication intrafamilial deficits and inadequate pain control.
Patients who beneficiate of care for secondary cancers experienced previously cancer with all its physical-social and psycho-emotional implications, and prepare now to die second time.
Conclusions : secondary tumors are more frequently intensely undifferentiated and from this point of view do not respond adequately to treatments. Clinical case presented along with medical bibliography sustains difficulties of care for secondary cancer patients, due to the second death, hastening death, alterated body image and non-accepting the self.
Keywords : secondary cancer, undifferentiated tumors, difficulties of care, palliative care, self deny, body image, hastening death, global pain.

Authors : Teodorescu H.1, Haidar A.2
1 "Victor Babes" Clinic, Bucharest
2 Colentina Clinical Hospital

Colorectal cancer (CRC) is the second leading cause of death due to cancer in the world. While CRC incidence is showing an increasing trend, screening for this form of malignancy becomes ever more important in an effort to reduce mortality through CRC.
CRC screening methods are used according to indication guidelines and include fecal occult blood test (FOBT), sigmoidoscopy, colonoscopy, double-contrast barium enema, virtual colonoscopy, genetic testing.
Keywords : screening, colorectal cancer.

Authors : Popa I.C.1, Erscoiu S.2, Stroie D.1, Tardei G.1, Nica M.1, Todiran A.1, Dascalu A.1
1 "Victor Babes" Clinical Hospital of Infectious and Tropical Disease, Bucharest
2 "Carol Davila" University of Medicine and Pharmacy, Bucharest

Introduction : Pneumocystis jiroveci infections (PCP) in HIV patients represent a diagnosis and treatment emergency in patients with advanced immunosupression (CD4 lymphocyte count inferior to 200 cells). Rapid initiation of specific salvatory treatment reclaims efficient and specific methods of diagnosis.
Material and method : We analyze diagnosis procedures of PCP infection in 20 patients treated in our clinic between 1st of January 2004 - 31 March 2010.
Results : PCP infection had occurred in known HIV-positives patients (9 cases - 45%) but also in non known HIV patients as first severe opportunistic life threatening infection (11 patients - 55%). Etiological diagnosis was précised by microbiologic methods in specimens of bronchoalveolar lavage (30%) and bronchial aspiration (10%), by clinical and radiological manifestations (55%). 3 cases (15%) were diagnosed in the last year by rt-PCR method for Pneumocystis jiroveci, recent available in our clinic, confirmed by classical microbiological examination, in patients without clinical and radiological definitory manifestations for PCP, but with favorable evolution under specific treatment. Global mortality was 20%, positive outcome being correlated with rapid establishment of etiological diagnosis and immunological host status.
Conclusions : PCP infection must be thought in HIV patients in immunological failure, with no or incorrect TMP-SMX prophylaxis, but also in patients with risk factors and classical signs for HIV infections, previously unknowns with AIDS. Routine bronchoscopy and rt-PCR technique in lavage fluid favors rapid initiation of treatment and improves the outcome. In the absence of these methods, empiric TMP-SMX treatment is a reasonable clinical attitude, for patients with known risk for PCP.
Keywords : HIV-AIDS, PCP infection, rt-PCR for Pneumocystis jiroveci.

Authors : Teodorescu H.1, Teodorescu C.2
1 "Victor Babes" Clinic, Bucharest
2 Colentina Clinical Hospital

Psoriasis is one of the most common skin conditions. Fatty liver disease (FDL) is a form of tissue damage in which fat accumulates in the liver cells. FDL can be caused by multiple factors. We aimed at determining the prevalence of FDL in psoriasis patients of our study lot. The patients were evaluated both in terms of dermatological and hepatological criteria. We made use of laboratory testing, patient's personal history and abdominal ultrasound. Psoriasis patients were assessed by Psoriasis Area and Severity Index (PASI) scoring. The study lot consisted of patients in early phases of treatment with biological agents.
Conclusions : Psoriasis patients with PASI score higher than 10 were found to have an increased prevalence of fatty liver disease.
Keywords : fatty liver, psoriasis.

Authors : Erscoiu S.1, Popa I.C.2, Stroie D.2, Tardei G.2, Ceausu E.2
1 "Carol Davila" University of Medicine and Pharmacy, Bucharest
2 "Victor Babes" Clinical Hospital of Infectious and Tropical Disease, Bucharest

Background : Until now, limited information exists regarding HIV infection among older patients. While older persons are at significant risk for HIV infection, they are almost universally omitted from prevention programs.
Objectives : The present paper analyses clinical and immunological status of HIV infection in older age, diagnosed and followed up in our clinic between 1995 and 2010. We studied the incidence of opportunistic infections (OP) and of cardiovascular, metabolic, neurologic and bone disorders, in conexion with the third decade of age, treated by HAART, the survival duration and the causes of death.
Methods : The retrospective study consists of patients diagnosed with HIV infection in age over 55 for women and 60 for men, the age of the beginning of the third decade, for the moment, in Romania. Demographic data were completed by complex nvestigations regarding HIV infection and these characterizing the diseases of older age.
Results : There were diagnosed 11 women (37.9 %) and 18 men (62.1 %) with the mean age of 64.5 for women respectively 62 for men. The clinical and immunological stage at the moment of HIV diagnosis was C3 in the majority of cases. HAART received 19 patients (65.5 %) during a mean period of 68,8 month. The mean of survival was 37.2 month. OI were the cause of death in 10 of 13 expired patients. 14 patients in our group study had cardiovascular diseases, 7 patients had chronic neurological disorders, 11 patients had varying types of neoplasic diseases.
Conclusions : The impact of HIV/AIDS on older adults has consistently been denied until now in comparison with other risk groups (children, young people). HAART management on older age must be better study. The interdisciplinary collaboration and a better social assistance must be implemented in that category of patients.
Keywords : HIV infection, older age, survival.

Authors : Ene L.1, Avram C. 1, Talianu D.2, Suditu St.2, Nica M.1, Diaconu A.1, Ceausu E.1, Duiculescu D.1
1 "Victor Babes" Clinical Hospital for Infectious and Tropical Diseases, Bucharest
2 Bagdasar-Arseni Emergency Hospital, Bucharest

Introduction : CNS infection with multi-drog resistant (MDR) Acinetobacter baumanii is an important issue regarding the therapeutic approach as well as medication penetrability of the blood-brain barrier, especially in patients with ventriculo-peritoneal drainage systems. We present the case of a patient with MDR Acinetobacter baumanii and Enterococcus faecalis ventriculitis treated locally with Colistin.
Results : The 19 year old patient with internal hydrocephalus since the age of 7, with ventriculo-peritoneal shunt and low pressure valve was infected with Acinetobacter baumanii and Enterococcus faecalis, the probable source being an abdominal infected cyst. Although initially it was considered a colonization of the drainage tube with biofilm developing A. baumanii, the sterilization of the drainage tube was not obtained even after several replacements of the prostetic material under antibiotic coverage with high dosage Meropenem. This observation, together with the lack of microorganisms at the lumbar puncture, led to the diagnosis of ventriculitis and the intraventricular administration of Colistin was the next step taken into consideration. Given the impossibility of removing the drainage sistem and valve, an Omaya catheter was introduced and used to administer Colistin 5 mg (50.000 UI) /day. The Colistin was relatively well suported by the patient, except for a transitory episode of chemical ventriculitis.
Conclusion : The use of intraventricular Colistin represents an option for the patients with CNS multi-drog resistant Acinetobacter. Sterilizing the CNS infection is very challenging when maintaining the ventricular drainage is necessary.

Authors : Gherlan G.1, Comsa F.1
1 "Victor Babes" Clinic, Bucharest

Riedel's lobe of the liver, first described by Bernhard Moritz Carl Ludwig Riedel, is an anatomical variation, a downward tongue shaped projection of the right hepatic lobe of the liver. It has been first described as an accessory lobe, but it is not a true hepatic lobe. The clinical significance of Riedel's lobe resides in its inclusion in the differential diagnosis of a palpable mass in the right abdomen. The incidence of Riedel's lobe in population varies considerably from study to study, from 3.3% to 31%. It seems to be more frequent in women than in man. Sometimes, as in the presented case, it can reach down to the iliac crest.
We present the case of a 53 years old woman, with previous history of pelvic surgery, in the genital sphere. She had made a toraco-abdominal CT scan at her own initiative wich only showed nontumoral hepatomegaly. The laboratory investigations showed no signs of liver disfunction.
It is now considered Riedel's lobe only a case of extreme downward elongated liver, of unknown origin, maybe intraperitoneal or intrapelvic inflammation or secondary to surgical interventions. Altough downward elongation of the liver is frequently described at CT or ultrasonography, typical cases of Riedel's lobe are rare.
Usually this condition requires no treatment. The clinical utility of this diagnosis is that sometimes liver tumors or metastasis can occur only in the lowest portion of Riedel's lobe, which being situate in the right iliac fossa may be omitted from some targeted explorations. Frequently Riedel's lobe is separated from rest of the liver by a transverse narrowing of the hepatic parenchyma, which may lead to the torsion of the lobe and may require surgery.
Keywords : Riedel, hepatomegaly, hepatic lobe, CT, ultrasonography.

Authors : Tanase A-M.1, Pineau P.2, Dima S.3, Dumitrascu T.3, Oprisan G.4, Marchio A.², Dinu S.4, Dejean A.2, Popescu I.3
1 "Victor Babes" Clinic, Bucharest
2 Unité d 'Organisation Nucléaire et Oncogenèse, INSERM U579, Institut Pasteur, Paris, France
3 Institute of Digestive Diseases and Hepatic Transplantation Fundeni, Bucharest, Romania
4 Molecular Biology Laboratory, "Cantacuzino" National Institute for Research/Development of Microbiology and Immunology, Bucharest, Romania



Background and aims : On a global basis, there are more than 626,000 new cases per year of primary liver cancer (PLC), almost all being HCC, and approximately 598,000 patients die from this cancer every year. The patients' outcome varies widely within each stage despite the surgical intervention. The current staging systems are not sufficiently predictive of outcomes. Molecular markers of tumor progression seem to be the strongest predictors of HCC recurrence.
Methods : Between November 2007 and November 2008 we performed a prospective study within 31 patients with primary liver cancer - 24 HCC and the rest of them had CCC, who underwent hepatic resection for liver cancer. A histopathologic as well as a genetic analysis was performed in resected specimens; the fractional allelic loss (FAL) was determined in each case.
Results : The patients had been follow-up for 12 months (US/CT -scan + serum AFP level). Local recurrence occurred in 10 (31%) patients, and other 6 (19.35%) patients had died (1 death from postoperative complications was excluded) from recurrent disease. FAL was studied in all patients and that was a significant difference among the 3 groups with mean FAL lower in patients with good outcome (27.38 versus 30.14 in patients with recurrence and 31.78 in deaths). The mean tumor diameter was similar between patients with recurrence and those without (6.32 versus 6.25); others parameters - TNM staging, Edmonson-Steiner classification, hepatic parenchyma status (cirrhotic/normal) - had been also studied.
Conclusions : FAL seems to strongly correlate with outcome in patients with liver cancer and asserts in front of the previous prognostic factors, suggesting the relevance of tumor's molecular biology. Therefore, systematic study of these genetic markers will provide a better assessment of PLC patients, improving therapeutic decisions making.
Keywords : FAL (Fractional Alelic Loss), primary liver cancer, follow-up.

Authors : Orban Schiopu A.M.1
1 "Elias" Emergency University Hospital, Bucharest

The aim of our study was to find if diabetes mellitus can aggravate acute gastrointestinal hemorrhage in cirrhotic patients.
We analyzed 50 patients with hepatic cirrhosis VHC, and hematemesis: 28 cases having also diabetes (group A) and 22 cases without diabetes (group B). The endoscopic examination allows us to find the following causes of hematemesis: esophageal varices (9 cases), hemorrhagic gastritis (25 cases) and duodenal ulcer (16 cases).
We compared group A with group B and noticed that acute upper gastrointestinal hemorrhage as well as its consequences (hemorrhagic shock, hepatic encephalopathy, and ascites, rebleeding) were more severe in group A. By ultrasonography examination we found in group A a lot of cases with gastric and duodenal stasis (24 versus 10 cases in group B).
We think that gastric and duodenal dismotilities in group A are due to associated diabetes and can aggravate acute upper gastrointestinal hemorrhage allowing the persistence of AINS tablets or producing the duodenogastric as well as gastro esophageal reflux which can harm gastric mucosa and variceal wall.
Keywords : diabetes mellitus, upper gastrointestinal hemorrhage.

Authors : Teodorescu H.1, Dumitrescu St.1, Tudor A.1
1 "Victor Babes" Clinic, Bucharest

Endoscopy of upper gastrointestinal and colonoscopy are key dignostic tools that have proven to deserve the importance place they occupy in the GI diagnostic algoritm.
We will present some cases from our experience of GI tract endoscopy in "Victor Babes" Clinic and will discuss the significance of observing the indication guidelines for endoscopical procedures.

Authors : Raducan E.1, Albulescu L.1, Popescu I.D.1, Albulescu R.1, Codorean E.1, Neagoe A.I.1, Stanculescu R.2, Tanase C.1
1 "Victor Babes" National Institute for Research and Development in the Field of Pathology and Biomedical Sciences, Bucharest
2 "St. Pantelimon" Emergency Hospital, Bucharest

Introduction : Worldwide, cervical cancer is a leading cause of cancer morbidity and mortality in women, despite increased screening efforts. Infection with specific subtypes of human papillomavirus (HPV) - HPV16 has been strongly implicated in cervical carcinogenesis. The serum levels of cancer antigen CEA and CA 125, as tumor markers, are useful in the diagnostics of cervical cancer. Soluble cytokine receptors play key roles in regulating cytokine-mediated biological events and their levels could provide additional information about human disease.
The aim was to evaluate the aggressive potential of tumors by determining serum levels of some classical markers and to perform a preliminary evaluation on soluble cytokine receptors in HPV.
Material and methods : The serum collected from 57 cervical cancer patients (22 for ELFA and 35 for Luminex analysis) and 24 controls was included in this study. The serum concentration for CEA and CA125 was measured by enzyme-linked fluorescent immunoassay technique (ELFA). Cytokine receptor levels (sEGFR, sVEGFR2/sKDR/sFlk-1 and sIL-2R/sCD25) were analyzed using xMAP technology (Luminex® 200™).
Results : The values obtained for the CEA in serum patients varies between <0.5 ng/mL and 7.2 ng/mL, with an average of 1.19 ng/mL (p=0.1); CA 125 between <4 IU/mL and 238 IU/mL with an average of 23.58 IU/mL (p=0.05).
Differences have been noticed between serum levels of EGFR and VEGFR2 in HPV-induced cervical neoplasia samples compared controls. However, mean values for sIL-2R were increased in samples from cervical cancer patients compared to controls. Modifications of EGFR and VEGFR2 levels were statistically significant and showed a good potential of prediction ROC areas of 0.795 for EGFR and 0.848 for VEGFR2.
Conclusion : The use of multiplex xMAP technology made possible the simultaneous quantitation of serum levels for several relevant molecules in HPV-induced cervical cancer. Further analysis is required in order to establish if soluble cytokines receptors could be used within an extended panel for prognosis in HPV-induced cervical neoplasia.
Keywords : HPV, soluble cytokines receptors, cervical cancer.
(*) This project was supported by Grant PNII 61-044.

Authors : Popescu I.D.1, Raducan E.1, Albulescu L.1, Codorean E.1, Albulescu R.1, Neagoe A.I.1, Tanase C.1
1 "Victor Babes" National Institute for Research and Development in the Field of Pathology and Biomedical Sciences, Bucharest

Introduction : Brain tumors are characterized by invasive growth and neovascularization potential. The vascular endothelial growth factor (VEGF) and the basic fibroblast growth factor (bFGF) - two potent angiogenic markers that stimulate vascular endothelial cell proliferation - are involved in the neoplastic angiogenesis of several types of tumours, including glioblastomas.
The objective of the study was to quantify the levels of these two key angiogenic activators (VEGF and bFGF) in glial tumors and to determine their potential role as diagnosis markers.
Methods : Serum levels for VEGF and bFGF were determined in 16 patients with glial tumors and in 10 healthy subjects, using ELISA and xMAP array technology. Immunohistochemical analysis was performed for angiogenic factors on paraffin-embeded sections from glial tumors samples.
Results : Serum levels for VEGF in patients ranged from 985 to 285 pg/ml, with the mean value 405.75 pg/ml versus 114.8 pg/ml in healthy individuals (p<0.05).
Mean values of bFGF serum levels were 43.10 (with values from 25.2 to 90 pg/ml), versus 10.7 pg/ml in healthy individuals.
For VEGF level, the above results were sustained by xMAP Array technology. A correlation was also noticed between the serum level for angiogenic markers and the immunohistochemical analysis.
Conclusions : Increased values of growth factors - VEGF, bFGF - correlated with a high histological tumor grade.
Our results showed VEGF and bFGF as useful biomarkers in diagnosis and monitoring of glial tumors.
Keywords : Angiogenic factors, VEGF, bFGF.
(*) This project was supported by Grant PNII 62-087.

Authors : Zidu M.1
1 "Victor Babes" Clinic, Bucharest

Introduction : Cavitary lung lesions may pose complex problems in terms of differential diagnosis as their etiological spectrum includes multiple entities : 1. infectious (bacterial, parasitic, fungal) 2. non-infectious (malignancies, vasculitides, colagenoses, embolic lesions, traumatic lesions, congenital lesions).
Case description : We are presenting the case of a 60 y.o. patient, non-smoker, with significant, 20-year long occupational exposure to crystalline silica dust and iron powder, with DM, with a metallic aortic prosthesis, under long term anticoagulant therapy. The case patient presented to our clinic with 2 month of dry cough. Physical examination of the respiratory system revealed no abnormal findings. PA chest radiograph highlighted multiple nodular opacities in the right lung field, one of which featuring air-fluid level. The contrast enhanced CT scan of the thorax show cavitary lesions in the right upper lobe, some of them presenting inner septation walls and one with air-fluid level. Let it be mentioned as well that one of the opacities fount on the initial chest X-ray examination, located in the right cardiophrenic angle, featured characteristics different than those from the upper lobe, suggestive of pleuro-pericardial cyst. Bronchoscopy showed no endoluminal changes in the examined area; bronchoalveolar lavage (BAL) showed eosinophil dominated cellularity, with no evidence of malignant cells. Ziehl-Nielsen staining of BAL specimen was negative for tubercle bacilli. Bronchial aspirate specimen was cultured for mycobacteria, with negative result. Transbronchial biopsy of the right upper lobe showed no evidence of malignancy. Concomitantly, the patient's blood work showed leukocytosis with significant eosinophilia, biological inflammatory syndrome, and positive Echinococcus granulosus serology. Under the circumstances, transbronchial biopsy was no longer considered necessary. The patient is currently receiving antiparasitic treatment with Albendazole 400 mg/day, and is expected for clinical and radiological re-evaluation in 30 days time.
Conclusions : Differential diagnosis of cavitary lung masses is often complex, requiring several procedures: imaging (conventional radiology, contrast-enhanced CT scan), bronchoscopy with bronchoalveolar lavage, transbronchial biopsy, transthoracic needle biopsy, serological and immunological lab tests. In this particular case, the potential risks of diagnostic procedures are worth mentioning (risk of tracheobronchial dissemination).
Keywords : cavitary lung lesions; bronchoscopy; bronchoalveolar lavage; transbronchial biopsy; transthoracic needle biopsy; Echinococcus granulosus.

Authors : Bucsa S.S.1
1 "Victor Babes" Clinic, Bucharest

Bronchopulmonary infections are complications frequently encountered on patients with congenital or acquired immune deficiency.
In the last decade was recorded a significant increase the number of immunosuppressed patients due to enlargement HIV infections, common use of organ transplants and increasing life expectancy for cancer patients who use chimioterapy.
I present three clinical cases with similar radiological, respectively lung opacity but which had different evolution and etiology depending on the host's immune status.
First case is a community acquired pneumonia with Haemophilus influenzae involvind unbalanced diabetes and chronic alcoholism; second case is pulmonary tuberculosis at patient with chronic hepatitis C after treatment with interferon; third case is allergic bronhopulmonary aspergillosis at patient with asthma and normal immune status.
Common feature of all cases is monomorphic radiological appearance which contrasts with the etiologic polymorphism.
Conclusions: Conventional chest radiography remains one of the basic methods in diagnosis of respiratory disease but may also surprise if not backed by other methods of investigation with high accurancy in order to orient towards the correct diagnosis.
Key words : Allergic bronchopulmonary aspergillosis, pulmonary tuberculosis, haemophilul influenzae, immune status.

Authors : Florescu G.1,Popescu C.2, Popescu R.2, Chirita D.3, Margaritescu I.3, Calistru P.1
1 "Victor Babes" Clinic, Bucharest
2 Colentina Clinical Hospital, Dermatology Clinic
3 Central Clinical Emergency Military Hospital, Dermatology Clinic, Bucharest

Fish tank granuloma is a rare skin condition, caused by Mycobacterium marinum, manifested as cutaneous nodular lesions with chronic course.
The infection is transmitted through contact with contaminated fish tank or swimming pool water.
We present the case of an 11 y. o. girl, who developed a slightly inflammatory, persistent nodule on the volar side of the left hand, subsequently ulcerated.
Shortly thereafter, similar nodules appeared on the dorsum of the left hand and on the front arm, with sporotrichosis-like extension.
Positive diagnosis was determined by the pathologic features, clinical manifestations, as well as the the epidemiological context.
Under treatment with Clarythromycine, the clinical course was favorable.
Skin infection with Mycobacterium marinum, although rare in children, should be suspected in cases of chronic nodular lesions, with linear extension.
Keywords : fish tank granuloma, child, tropical fish tank.

Authors : Cristea C.1, Ceausu E.1, Clondireanu I.1, Nedu E.1, Florea M.1, Stoicev T.1, Mereuta S.1, Zolotusca I.1
1 "Victor Babes" Clinical Hospital for Tropical and Infectious Diseases, Bucharest

Objectives : To asses the aspects on the epidemiology, clinical findings and the outcome of the adults diagnosed with 2009 influenza AH1N1.
Methods : A total number of 116 patients were admitted in the "Victor Babes" Clinical Hospital of Infectious Diseases between August 5 2009 - February 6 2010, with the diagnosis of influenza AH1N1. The diagnosis of influenza AH1N1 was suspected on epidemiological and clinical grounds and was confiermed by real time RT- PCR, from throat and nose swabs collected on the admision day. ("Cantacuzino" Institute).
Results : The patients's age was between 18 - 83 years old, the rate f/m was 68/48.107 pacients(92.2 %) have presented mild and uncomplicated illness, 9 patiens (7.8 %) became critically ill.Criteria for transferring critically ill patiens to ICU care : rapidly progressive respiratory failure with refractory hypoxaemia to oxygen administration (2 cases), multi-organ dysfunction (2 cases). 112 pacients (96.5 %) have experienced uncomplicated influenza infection with full recovery , even without oseltamivir treatment.
Conclusions : 92.2% of pacients have experienced mild to moderate uncomplicated illnes, 7.8 % presented complicated forms.The severe forms were met in healthy adults before illness and in pacients with chronic respiratory conditions too.The most frequent complication in severe pacients was bronchopneumonia with respiratory failure, in 3% of this patients mechanical ventilation was necessary.
Keywords : AH1N1, 2009 influenza, oseltamivir, respiratory failure.

Authors : Vasile (Preda) G.1,2, Buriu M.1, Cretu A.M.2,3, Rosoiu N.2
1 MEDSTAR 2000 Medical Center, Constanta
2 OVIDIUS University Constanta - Faculty of Natural and Agricultural Sciences, Biology and Biochemistry Department
3 County Clinical Emergency Hospital of Constanta

Helicobacter pylori is a microaerofil pathogen that colonizes gastric mucosa of approximately half the world population, as it has been observed in various studies by titration of Helicobacter pylori IgG antibodies. The prevalence of infection varies from one region to another. This bacterium is considered to be one of the most important etiological agents of chronic active gastritis and peptic ulcer disease. The immune response of the organism is revealed by the appearance of a local inflammatory process with release of reactive oxygen species.
The study's aim was to quantify and analyze the systemic immune response achieved in Helicobacter pylori infection. For this was determined a number of specific and unspecific markers of inflammation, such like total antioxidant capacity (TAC), total oxidant status (TOS), oxidative stress index (OSI), erythrocyte sedimentation rate (ESR), WBC count, C-reactive protein and fibrinogen, correlated with the degree of infection determined by titration of Helicobacter pylori IgG antibodies. One of the conclusions drawn following the analysis and interpretation of data was that at systemic level the Helicobacter pylori infection resonance is medium to minor in the absence of such diagnostic tests, and diagnosis of Helicobacter pylori infection is necessary for successful treatment of any gastrointestinal manifestations.
Keywords : Helicobacter pylori, gastrointestinal manifestations, inflammation, oxidative stress.