Lege Artis Medicinae

[NEUTROPENIA AND SUBSEQUENT INFECTION IN HEMATOLOGICAL DISEASES]

SINKÓ János

MAY 20, 2005

Lege Artis Medicinae - 2005;15(05)

[Neutropenia is an immunocompromised state commonly occurring in hematological practice. The underlying disorder responsible for a critical drop in absolute granulocyte count can either be of congenital or acquired nature. Neutropenic patients frequently develop serious, at times even fatal infections. Severity of illness, outcome, type of infecting organisms are markedly influenced by additional risk factors such as impaired T- or B-lymphocyte function as well as the injury of biological barriers. Neutropenic infections should generally be treated according to evidence-based guidelines. However, in certain groups of patients, where randomized trials are lacking, all identified components of immunodeficiency should be taken into account and antimicrobial treatment or prophylaxis should individually be tailored.]

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Lege Artis Medicinae

[ISOTOPE BASED CARDIAC DIAGNOSTICS - POSSIBILITIES IN NUCLEAR CARDIOLOGY]

BALOGH Ildikó

[Methods of nuclear cardiology have been applied for several decades and there is continuous development in this area. The most commonly used modality is the myocardial perfusion scintigraphy (MPS). During stress MPS, the presence and the severity of ischaemic heart disease (IHD) can be detected. Resting MPS can show a freshly developing acut myocardial infarction (AMI) immediately, but new and old infarcted myocardial areas can not be distinguished by this method. Using SPECT (single photon emission tomography) examination and quantitative analysis can improve the accuracy of MPS. With gated SPECT we can analyse both the perfusion and the function of left ventricle. To examine the function of left and right ventricle the “gold standard” non-invasive method is MUGA (multiple gated acquisition) of blood pool scintigraphy. After only a few hours of the onset of AMI we can detect it with the socalled infarct avid scintigraphy using radiopharmaceuticals which accumulate in affected area. Following an AMI it is essential to differentiate among high and low risk patients for revascularisation treatment, therefore distinguishing the viable (hibernating) and non-viable (necrotic) myocardium with imaging techniques is an important task. Preserved metabolism as the sign of viable myocardium can be detected both by SPECT (most accurately by thallium rest-redistribution scintigraphy) and PET (detecting glucose metabolism by F-18-FDG). Adrenerg receptor scintigraphy can show the sympathetic innervation: in the case of a transplanted heart it can detect the reinnervation and in the case of malignant ventricular tachyarrhythmias the risks and the severity of the illness.]

Lege Artis Medicinae

[CURRENT PRACTICE AND PROBLEMS IN RESUSCITATION]

DIÓSZEGHY Csaba

[Cardiopulmonary resuscitation is the progressive management of sudden cardiac arrest with the goal of restoring spontaneous circulation and preserve vital organ functions. Sudden cardiac death occuring out of hospital is still one of the major causes of death among otherwise healthy and young population however, approppriate management - certainly including resuscitation as the first step - might provide a reasonably good quality of life. Long term outcome of resuscitation is mainly determined by the links of the Chain of Survival, eg. early access, early CPR, early defibrillation and early advanced care. The aim of this review is to present the upto- date concepts for the best management of these survival links.]

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[In the focus: Dermatology]

HORVÁTH Attila

Lege Artis Medicinae

[SCD-HeFT]

MATOS Lajos

Lege Artis Medicinae

[THE ROLE OF REGISTRY ANALYSIS IN THE FORMING OF THERAPEUTIC GUIDELINES IN RENAL TRANSPLANTATION]

PERNER Ferenc, HERCZEG Balázs, SZENOHRADSZKY Pál, ASZTALOS László, KALMÁR-NAGY Károly, JÁRAY Jenő

[The authors assess the two main outcomes of the immunosuppressive therapy after renal transplantation: graft and patient survival. According to their view, evidence from randomised clinical trials results can be well complemented by the several unique transplant registries and outcome research based upon these databases. The comparison of evidence from these two sources addresses the question of achievable outcome under ideal (controlled) versus real life conditions. Based on a systematic review of the relevant clinical trials and registries it can be stated, that in the case of some immunosuppressants (mycophenolate mofetil vs azathioprine, microemulsified cyclosporin vs cyclosporin and tacrolimus vs cyclosporin) the improvement in the intermediate outcome can lead to improved graft and patient survival, while in the case of other drugs no significant difference in hard endpoints were detected (tacrolimus vs microemulsified cyclosporin). Evidence on graft and patient survival differences could not be derived from traditional randomised clinical trials, only from transplant registries. For the sake of improved evidence based therapeutic guidelines in renal transplantation, authors call for further development of the Hungarian transplant registry.]

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[ANTIBIOTIC TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS - THE USE OF RESPIRATORY FLUOROQUINOLONS]

MAGYAR Tamás

[The paper reviews the classification and grading of skin and soft tissue infections and their most common pathogens. The recommended antibiotics are itemized taking into account their antibacterial and pharmacokinetic properties and side effects. The use of levofloxacin, an antibiotic that have so far been almost exclusively given in respiratory tract infections, is noted as a new therapeutic option. In unusually severe infections hospitalisation of the patient can be avoided since levofloxacin can also be prescribed by general practitioners. Both published data and the author's own experience suggest that levofloxacin may gain a prominent role in the treatment of skin and soft tissue infections both in primary and specialist care.]

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LUDWIG Endre, KRIVÁN Gergely

[Studies performed in the past few years have confirmed that vitamin D is essential for maintaining the optimal immune defense, and its immunomodulatory effect has a role in the defense against infections as well. A lot of data suggest that low serum 25-(OH)-D concentration is associated with an increased frequency of certain infections and it adversely influences pathological processes. Data on this adverse effect are available mostly in case of Mycobacterium tuberculosis, respiratory viral infections in general, HIV, hepatitis C and sepsis. The outcomes of severe infections are usually influenced by a number of factors and it seems that vitamin D deficiency is one of those factors that shift the process towards an unfavourable outcome. Further studies should evaluate the significance of this role and the influence of vitamin D supplementation on pathological processes.]

Hungarian Immunology

[Immunology of Felty’s syndrome]

BÁLINT Géza, BÁLINT Péter

[Felty’s syndrome can be regarded as “super-rheumatoid” disease. Immungenetically the syndrome is much more homogenous, than rheumatoid arthritis. HLA-DRB1*0401 antigen is present in 83% of the patients. Felty’s syndrome develops usually after a longer course of rheumatoid arthritis, in 1% of rheumatoid patients. Rheumatoid arthritis patients with long lasting unexplained neutropenia can be diagnosed having Felty’s syndrome, even without detectable splenomegaly. On the contrary, rheumatoid arthritis with splenomegaly, but without present or previous neutropenia with unexplained origin cannot be regarded as having Felty’s syndrome. Inspite of the fact, that the arthritis of Felty’s syndrome can be inactive, because of the neutropenia and increased risk of recurrent infections, the patients should be kept under tight supervision, and should be properly treated, if required. Immunologically Felty’s syndrome is characterized by rheumatoid factor positivity in 95-100%, ANA positivity in 50-100%, antihistone positivity in 63-83%. Antibodies against dsDNA rarely, but against ssDNA frequently occur. No anti Sm and interestingly no anti Ro and anti La antibodies can be detected inspite of the high incidence of associated Sjögren’s syndrome. Immunoglobulin levels are higher and complement levels are lower, than in rheumatoid arthritis. Circulating immuncomplex level is usually high. Non-specific antineutrophil anticitoplasmatic antibodies can be found in high percentage. The neutropenia of Felty’s syndrome can be either caused by increased IgG neutrophilic binding activity or by inhibition of the granulocytes colony growing in the bone marrow, by peripheral blood mononuclear cells. Expansion of large granular lymphocytes can be seen in 30-40% of patients with Felty’s syndrome. Large granular lymphocyte syndrome is not rarely associated with rheumatoid arthritis. The neutrophil account is normal or elevated in this syndrome, but splenomegaly occurs. These cases are called as pseudo Felty’s syndrome. The patients with Felty's syndrome suffering from recurrent infections required treatment even if the arthritis is inactive. Methotrexate treatment should be started first, if this treatment fails, other disease modifying drugs or colony stimulating factor can be given. There is no experience with other biological treatments. In treatment of resistant cases splenectomy is indicated. Non-steroid anti-inflammatory drugs should be better avoided.]

Lege Artis Medicinae

[Catheter related infection caused by Rhizobium radiobacter in hemodialysis patient]

SÁGI Veronika, OROSZ Attila

[INTRODUCTION - Rhizobium radiobacter is a rare opportunistic pathogen. The bacteria present in soils causes systemic infection mostly in immuncompromised patients and frequently forms biofilm on intravascular and other indwelling plastic catheters. Majority of the pathogen stems shows sensitivity to cephalosporins, carbapenems and ciprofloxacin. CASE REPORT - In case of our hemodialysis patient a vegetation developed on the tip of the tunneled central venous catheter. The patient was exposed to dust emerging from soil during agricultural work before the infection. After removal of the intravascular device and ceftazidim treatment for seventeen days the patient recovered. CONCLUSION - Overcoming the infection is in greater part of the cases only possible if the plastic device is removed because it forms an infective focus.]

Lege Artis Medicinae

[CRITICAL SITUATIONS IN SYSTEMIC AUTOIMMUNE DISEASES]

KISS Emese, SOLTÉSZ Pál, RÉTI Katalin, POÓR Gyula, SZEGEDI Gyula

[Systemic autoimmune diseases characteristically show multiple organ involvements. Hence, Clinical manifestations and the outcome are quite variable. The survival has continuously been improving due to more sophisticated diagnostic tools and therapeutic possibilities. Despite the technical development, complications and organ manifestations may lead to emergency or often provoke permanent functional or morphologic deterioration of the affected organs. Critical situations can be directly attributed to the manifestations of the underlying disease, deterioration of the affected organs, side effects of immune suppressive therapy complications of Intercurrent or co-incidental diseases also may induce the occurrence of critical complications. The Authors describe all conditions that may lead to the development of critical situations at systemic autoimmune disease regarding different organ and organ systems. The symptoms and diagnostic possibilities are also analysed. A checklist is given about those systemic autoimmune disorders where particular critical events can be present. Medication in general and other possible immune modulator managements with beneficial effects are discussed.]