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Lege Artis Medicinae

NOVEMBER 03, 2015

[Current questions on Pneumococcus infections: cardiovascular complications, cardiotoxicity and new opportunities for prevention among elderly people]

LUDWIG Endre

[The respiratory tract infections, first of all severe pneumonia are associated with severe cardiovascular adverse events the significance of which that had not been recognised so far. Among the adverse events, the development of acute coronaria syndromes, heart failure, arrhythimias are the most important ones leading to significatly higher mortality even after several years. In the development of acute coronaria syndrome , the proinflammatory activites play the cenral role leading to the instability of coronaria plaques and plaque rupture associated with formation of platelet thrombi. The constriction of coronariae, peripherial vasodilatation and hypoxia also contribute to the deleterius complications. The role of pneumococci in this process seems to be especially significant since this pathogen exhibit a unique direct cardiotoxic effect, namely directly invades the myocardium and produce cardiotoxic substances. As a consequence, impairement of cardiomyocite function and contractility and formation of microscopic lesions in which later collagen deposition and long-term cardiac scarring can be detected. These pathological processes are developed despite of antibiotic treatment, consequently, vaccination against pneumococcal infection seems to be the only method for efficacious prevention of the myocardium damage and cardiovascular adverse events. According to the results of the CAPITA study, the conjugate polisaccharide vaccine decrease the number of pneumococcal pneumonia and invasive pneumococcal infections by 45 and 75% resp. in the elderly population. The recognition of the direct and indirect role of pneumococci in the development of early and late cardiovascluar adverse events gives a new aspect of the beneficial effect of efficacious vaccination.]

Lege Artis Medicinae

APRIL 20, 2014

[Vaccine coverage of invasive and carried Streptococcus pneumoniae isolates in Hungary]

TÓTHPÁL Adrienn, LAUB Krisztina, KARDOS Szilvia, NAGY Károly, DOBAY Orsolya

[Vaccination against Streptococcus pneumoniae will be mandatory for infants and children from 1 July 2014 in Hungary. Since the introduction of the conjugate vaccine against Pneumococcus, the distribution of Pneumococcus serotypes has changed significantly. Surveillance data from the National Centre for Epidemiology show that certain vaccine-type pneumococcal serotypes have almost disappeared owing to the immunization program, while other serotypes have emerged. Nowadays serotype 3 and the multiresistant 19A serotype are the most frequent causes oif invasive infections. A study analysing the nasal carriage of children attending kindergartens also confirmed the decline of vaccine- serotypes parallel to vaccination coverage and the simultaneous emergence of previously very types, such as 19A. The most recent study examining nasal carriage of children attending nursery (age < 3 years) showed that the 13-valent conjugate vaccine has efficiently decreased the carriage of serotypes 3 and 19A, verifying that the immunisation program should be continued using the vaccine providing the broadest coverage against Pneumococcus.]

Clinical Neuroscience

JANUARY 30, 2014

[Pneumococcal meningitis in a pregnant woman]

SCHAREK Petra, JEKKEL Csilla, BUDAI József, SZILASI Zsuzsanna, HELFERICH Frigyes, ÁRVA Ilona, VÁRADI András, LÉTAY Erzsébet, KATONA Katalin, RÓKUSZ László

[Bacterial meningitis is a life-threatening disease. The incidence of meningitis is about 2.6-6 cases per 100.000 adults per year in developed countries. The most common causative microorganisms are Sreptococcus pneumoniae and Neisseria meningitidis. A 33-year-old multigravida, at 24 week of gestation was admitted to the hospital because of ear pain, haedache, fever and confusion. Lumbal puncture was performed and cerebrospinal fluid analysis showed signs of bacterial meningitis. Latex agglutination test was positive for S. pneumoniae, Gram-positive diplococci have seen under microscope and later cultivation verified S. pneumoniae as the causative agent. After ceftriaxon, dexamethasone administration and treatment in intensive care unit, left side mastoidectomy was performed since cranial computed tomography showed acut exacerbation of chronic mastoiditis on the left side. After extubation, mobilisation and 14 days antibiotic treatment the patient, who had residual hearing loss on the left side, was discharged from the hospital. During the treatment the foetal parameters were normal. The patient at 39 week of gestation gave birth to a healthy infant. Forty-eight case reports have been published in this topic around the world until April, 2012. The most common causative agents were S. pneumoniae and Listeria monocytogenes. Because of the little amount of data, it is hard to appreciate the actual incidence and prognosis of this life-threatening illness both for mother and infant. As far as we know this is the first published case report of meningitis during pregnancy in Hungary. By this article we would like to draw attention to the importance of teamwork, of prevention of brain abscess formation and of the removal of the infection’s focus.]

Lege Artis Medicinae

NOVEMBER 20, 2005

[PREVENTION OF INFECTIONS IN CHRONIC HEPATITIS AND CIRRHOSIS]

PÁR Alajos, NEMESÁNSZKY Elemér

[Patients with chronic liver disease, mostly the elderly, due to their impaired immune response, frequently suffer from infections worsening the clinical course. This is sometimes overlooked in the everyday praxis. In patients with alcoholic liver disease both hepatitis A virus (HAV) and acute hepatitis B virus (HBV) infections can lead to fulminant hepatic failure, therefore their immunization with HAV and HBV vaccines is highly recommended, similarly, vaccination against flu and pneumococcus also may be indicated for alcoholics. In chronic viral hepatitis, alcohol abuse can result in rapid progression to cirrhosis and reduces the efficacy of antiviral treatment. Patients with chronic hepatitis C should also be vaccinated against superinfections by HAV and HCV. Co-infections by hepatotropic viruses and human immundeficiency virus (HIV) are frequent due to the shared routes of transmission. In HIVpositive patients the efficacy of the vaccination against HAV and HBV depends on the CD4 cell count, which also determined the timing of anti- HBV or anti-HCV treatment. Concerning the bacterial infections, spontaneous bacterial peritonitis (SBP) is the most severe complication of cirrhosis. The prevention of SBP is orally administered, moderately absorbed quinolon (norfloxacin) as long-term selective intestinal decontamination against Gram-negative pathogens. Alcoholic patients are also susceptible for tuberculosis. Bacterial infections play a role even in portal hypertension and variceal rupture, furthermore, both gastrointestinal haemorrhage and invasive endoscopic procedures increase the risk of infection, therefore in such situations a short-term (5- 8 day) antibiotic profilaxis is necessary with norfloxacin or ciprofloxacin. Taking into consideration these points of view, it may be of privotal significance for the management of patients with liver disease.]

Clinical Neuroscience

DECEMBER 20, 2008

[Pneumococcal meningitis in children - 9 1/2-year-experience at Szent László hospital, Budapest, Hungary ]

IVÁDY Balázs, LIPTAI Zoltán, ÚJHELYI Enikő, BALÁZS György

[Background and objective - No recent publications are available about pneumococcal meningitis in Hungarian children. The aim of this study was to collect data of epidemiological, clinical and prognostic features of pneumococcal meningitis in children treated at Szent László Hospital, Budapest, Hungary. Methods - We conducted a retrospective review of medical charts and follow-up records of patients aged 1 to 18 years admitted to our Pediatric and Pediatric Intensive Care Units due to pneumococcal meningitis between 1st Jan 1998 and 30th Jun 2007. Results - 31 children with 34 cases of pneumococcal meningitis were admitted to our hospital in the study period. Two children developed recurrent illness. The mean age was 6 years, 26% were under 1 year of age. The mean duration of hospital stay was 21 days, 97% required intensive care. Frequent clinical symptoms were fever (100%), nuchal rigidity and vomiting (78%), altered mental status (71%), Kernig's and Brudzinski's signs (58%) and seizures (41%). Otitis media, sinusitis, mastoiditis were present in 44%, 58%, 41%, respectively. Subdural effusion, parenchymal cerebral lesion and sinus thrombosis were documented in 5, 3 and 2 cases, respectively. One third of the patients recieved ceftriaxon, two thirds were administered ceftriaxon and vancomycin. Adjunctive therapy with dexamethason was given to 91% of the children. 70% of patients required mechanical ventillation. 9 patients (25%) required endoscopic sinus surgery. In 13 cases (38%) mastoidectomy, in 5 children (15%) neurosurgery was performed. The case fatality rate was 23.5%. 8 (23.5%) patients had mild or moderate, 1 child (3%) developed severe neurological sequelae. Conclusion - Pneumococcal meningitis in children remains a source of substantial morbidity and mortality in childhood. The long hospital stay, the frequent need for intensive care and severe neurologic sequelae emphasize the importance of early diagnosis, early treatment and prevention with pneumococcal conjugate vaccines.]