DOI: 10.3897/folmed.68.e173506

Authors: Matea Rebrina, Josip Begovac, Mirjana Stupnisek

Abstract: Introduction: Chronic kidney disease (CKD) represents a significant global public health issue among people living with HIV (PLWH). The use of antiretroviral therapy (ART) is associated with increased prevalence of CKD and decreased glomerular filtration rate (GFR). Aim: This study set out to investigate the prevalence of CKD, and to describe trends in different stages of CKD in HIV-positive patients treated in Croatia. Participants and methods: In this retrospective cohort study, data from 1,143 HIV-positive patients of both sexes, aged over 18, treated at the University Hospital for Infectious Diseases in Zagreb, Croatia, were analyzed. CKD was defined using the MDRD equation to estimate GFR. Data were collected from medical records with the approval of the Hospital’s Ethics Committee. Statistical analysis was performed using the SAS program. Results: A total of 4,166 eGFR measurements were performed, of which 88.6% were from male patients. The most represented age group was 30–39 years (32.89%). AIDS-defining illness developed in 27.36%, ART was received in 91.77%, and viral suppression was achieved in 83.20% of participants. The most commonly used ART combination was ABC/3TC/EFV in 29.12% of participants. The distribution of CKD stages was as follows: Stage 1: 33.63%, Stage 2: 63.38%, Stage 3A: 3.60%, Stage 3B: 0.67%, Stage 4: 0.31%, and end Stage 5: 0.41%. Conclusion: Patients on ART more frequently show mild deviations in eGFR compared to those not on ART. Despite the small sample size, an increasing trend in CKD was observed. Regular monitoring of kidney function enables recognition of CKD in the early stages.

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DOI: 10.3897/folmed.68.e184403

Authors: Kostadin Kostadinov

Abstract: The article by Poposki et al. on visceral leishmaniasis as a cause of fever of unknown origin presents clinically valuable observations but exhibits substantial methodological limitations. Differential exclusion of undiagnosed cases introduces selection bias and precludes generalizable prevalence estimates. The analytical strategy lacks etiological coherence by comparing a specific diagnosis against heterogeneous conditions. Multiple univariate comparisons without adjustment for family-wise error rate and absence of multivariable analysis to control confounding limit causal inference. The cross-sectional assessment of clinical features after diagnostic confirmation precludes temporal inference. Future studies would benefit from nested case-control designs, transparent reporting of diagnostic pathways, and appropriate statistical adjustment.

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DOI: 10.3897/folmed.68.e182189

Authors: Georgi Lukanov, Atanas Panev, Lubomir Tzvetanov, Kevork Kaykchian, Alexander Gerchev, Plamen Kinov, Slaveyko Djambazov

Abstract: Abstract Introduction: Total hip arthroplasty is one of the most successful modern surgical procedures, yet periprosthetic joint infection (PJI) remains a serious complication associated with disability and increased postoperative mortality. Aim: This study highlights the importance of identifying the causative microorganism and its antibiotic susceptibility profile for the successful application of a one-stage revision protocol in treating PJI. Materials and methods: Between October 2017 and July 2023, 33 patients underwent one-stage revision total hip arthroplasty. Preoperative joint aspiration and intraoperative periprosthetic tissue sampling were performed in all cases, with microbiological analysis conducted. The study group consisted of 15 men and 18 women, with a mean postoperative follow-up of 33 months (range 2–66 months). Results: A pathogen was identified in 31 patients. Staphylococcus epidermidis was the most common microorganism, responsible for 44.1% of infections. Staphylococcus aureus was found in 14.7% of cases. Enterococcus faecalis was isolated in three patients, and Serratia marcescens in two. No infection recurrence was recorded during follow-up. Complications included two postoperative dislocations, both managed with closed reduction, and one death due to pulmonary embolism. Functional outcomes improved, with the mean Harris Hip Score increasing from 54.3 preoperatively to 72.3 postoperatively. Conclusion: In this selected cohort, one-stage revision was associated with favorable short- to mid-term outcomes. These findings suggest that, when guided by precise microbiological diagnosis and multidisciplinary management, one-stage revision may be a viable option for carefully selected patients with periprosthetic hip infection.

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DOI: 10.3897/folmed.68.e172980

Authors: Blagovest Petrov, Kostadin Kostadinov, Ivan Dechev, Krasimira Eneva

Abstract: Background: Sexually transmitted infections (STIs) have been linked to male infertility; however, the available evidence from Eastern Europe is inconclusive. Aim: The present study therefore set out to assess the prevalence and etiology of STIs, focusing on Trichomonas vaginalis, among infertile Bulgarian men. Materials and methods: A retrospective monocentric study was conducted at Thorax Hospital, Plovdiv, between May 2018 and May 2024, on 359 infertile and subfertile men. The study adhered to the World Health Organization (WHO) guidelines for the evaluation of semen parameters. Ejaculate, prostatic secretions and urethral swabs were subjected to a culture and microscopy procedure for 16 pathogens. The associations between semen quality and these parameters were examined using t-tests, chi-squared tests and logistic regression. Results: Sexually transmitted infections were detected in 48.5% (174/359). Frequent pathogens were Ureaplasma urealyticum (29.5%), group B streptococcus (25.1%), Enterococcus spp. (13.9%), and coagulase-negative staphylococci (CoNS) (13.9%). The prevalence of T. vaginalis was 6.7% (24/359) and associated with lower progressive motility (β=−7.66 percentage points; p=0.028, uncorrected). Coinfections occurred in 42.1%, monoinfections in 39%. Prostatic secretions were more often positive than ejaculate (54.7% vs. 46.9%; p=0.06). No significant between-group differences were seen for sperm concentration (43.9 vs. 46.7 million/mL, p=0.307) or symptoms (21.3% vs. 27.6%, p=0.206). Multivariable models found no independent clinical predictors (all p>0.05), while pathogen burden correlated with motility (r =−0.152, p=0.004). Conclusion: Sexually transmitted infections (STIs), particularly U. urealyticum and T. vaginalis, are common in infertile Bulgarian men and often remain asymptomatic. Routine broad-spectrum screening, including prostatic sampling, is warranted to detect treatable causes and potentially optimize fertility outcomes. Prospective studies should determine whether the eradication of these infections improves semen quality. These findings emphasize the necessity for standardized, comprehensive diagnostics and meticulous interpretation of colonizers versus pathogens in infertility evaluations to inform management decisions.

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DOI: 10.3897/folmed.68.e160562

Authors: Meri Hristamyan

Abstract: Abstract Introduction: Human papillomavirus (HPV) infections are highly prevalent and are linked to a range of health conditions, from benign lesions to several oncological diseases. Safe and highly effective HPV vaccines have been developed; however, vaccination rates remain suboptimal in many countries, including Bulgaria. As future medical professionals, the attitudes and practices of healthcare students toward HPV vaccination are of extreme importance. Aim: To evaluate the attitudes and practices of university healthcare students regarding HPV vaccines. Materials and methods: An anonymous online survey was administered to a total of 245 medical, dental, and pharmacy students at the Medical University of Plovdiv, Bulgaria. Statistical analyses were performed using SPSS v. 24; p<0.05 was considered significant. Results: The majority of participants (86.5%, n=212) had not been vaccinated against HPV, but more than half (n=121) expressed a willingness to be vaccinated. The proportion of vaccinated individuals increased with the number of sexual partners reported in the previous year (χ2=10.44, p=0.033). Approximately two-thirds of the individuals surveyed (n=157) would recommend vaccination, with a higher likelihood among women (U=1848.5, p<0.001). Vaccinated respondents tended to have greater distrust of the myth regarding reproductive consequences (U=1926.0, p=0.002). Embarrassment was not perceived as a major barrier, but 21.2% (n=52) stated that cost was. There was a consensus among all majors on the necessity for enhanced awareness, which is particularly pronounced among medical students (H=13.13, p<0.001). Unvaccinated respondents had a higher interest in gaining more knowledge (U=1971.0, p=0.003), just like first- to third-year students (H=9.37, p=0.017). Conclusion: While overall vaccine confidence and attitudes are high, addressing specific concerns (such as safety, personal risk, and cost) could improve HPV vaccine uptake and acceptance.

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DOI: 10.3897/folmed.67.e167515

Authors: Kostadin Poposki, Dejan Jakimovski, Zaklina Shopova, Arlinda Osmani, Irena Trajkova, Mile Bosilkovski

Abstract: Abstract Aim: To evaluate the presentation patterns of visceral leishmaniasis (VL) as a cause of fever of unknown origin (FUO) and compare them with other FUO etiologies. Materials and methods: This prospective observational study was conducted at the Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of North Macedonia, from 2019 to 2025. We included ninety-four immunocompetent patients, aged 14 or over who met the FUO criteria by Durack and Street and had a definitive etiology subsequently established. Based on the final diagnosis, patients were categorized into those with VL and those with alternative FUO etiologies. Demographic, clinical, and laboratory data from standardized investigations were compared between the groups using appropriate statistical tests. Results: Sixty-six percent of participants were male, and their median age was 49 years (IQR 36–65). Infectious diseases were responsible for 52.1% of all FUO cases, followed by noninfectious inflammatory disorders (20.2%), miscellaneous causes (17%), and malignancies (10.6%). VL was the leading single diagnosis, identified in 17% of the total cohort. Compared with non-VL FUO cases, VL patients more often presented with weight loss, diaphoresis, and splenomegaly (all p<0.001), hepatomegaly (p=0.002), and higher febrile peaks (p=0.026). Hematologic abnormalities were more pronounced in VL, with lower hemoglobin, hematocrit, leukocyte, and platelet counts (all p≤0.006), as well as lower albumin (p=0.029) and higher globulin levels (p=0.001). Conclusion: Visceral leishmaniasis can be an important yet underrecognized cause of FUO in endemic regions. Greater clinical awareness and early diagnostic testing are essential to prevent delays and inappropriate treatment.

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DOI: 10.3897/folmed.67.e144634

Authors: Marina Raquel Gomes Coelho, Luzia Bismarck, Manuel Ribeiro, Rita de Mora Féria, Teresa Vilaça

Abstract: Q fever is a systemic zoonotic infection with a wide range of clinical presentations leading to a laborious diagnosis. We present a case of a 28-year-old man who was diagnosed with acute Q fever with typical hepatic and bone marrow involvement, characterized by acute hemolytic anemia, which is not commonly associated with this disease. This underscores the importance of including Q fever in the differential diagnosis when facing unexplained systemic or hematologic abnormalities.

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DOI: 10.3897/folmed.67.e142295

Authors: Christiana Anastasiadou, Antonio Pujante, Christos Giankoulof, Konstantinos Siozos, Stamatios Aggelopoulos, Angelos Megalopoulos

Abstract: Fungal embolism of the infrarenal aorta is a rare but critical complication of infective endocarditis, associated with significant morbidity and mortality. Outcomes depend heavily on timely detection and management. Here, we present an extremely rare case of acute aortic occlusion caused by Candida albicans originating from a valve other than the one that was replaced. This report emphasizes the importance of recognizing atypical manifestations of endocarditis in clinical practice and the need for early antifungal therapy in high-risk patients.

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DOI: 10.3897/folmed.67.e152506

Authors: Ravishtaashini Vanitha, Franziska Abelein, Kalina P. Stoyanova

Abstract: Introduction: Malaria is a significant global health problem, predominantly affecting the tropical regions. Aim: This study aims to analyze trends in imported and non-travel-related malaria cases reported in European countries from 2013 to 2022. Materials and methods: A retrospective analysis was performed based on the Malaria Annual Epidemiological Reports of European Centre for Disease Prevention and Control (ECDC), supplemented with information from regional parasitological reports and relevant scientific publications. Results: Over the past decade, more than 70,000 cases of malaria have been reported in Europe with an average notification rate of 1.011 per 100,000 population. The highest incidence (8,662) registered in 2019 and the lowest (2,480) in 2020 reflect travel restrictions imposed during the COVID-19 pandemic. Most cases (99.81%) are classified as imported. Among non-travel-related cases, local transmission is confirmed in 45.19%, 17.31% are hospital-acquired infections, 15.38% are classified as airport malaria, and 18.27% remained cryptic. Conclusion: Malaria remains a significant health risk in Europe due to persistent patterns of travelling and increasing immigration. The possibility and actuality of non-travel-related distribution should increase the vigilance of medical professionals against this severe, life-threatening disease.

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DOI: 10.3897/folmed.67.e139995

Authors: Atalay Kutlu, Akif Erbin, Turan Ozdemir, Ahmet Eren Sagir, Begum Calim Gurbuz, Halil Lutfi Canat

Abstract: Xanthogranulomatous pyelonephritis (XGP) is a rare and severe chronic inflammatory condition of the kidney. XGP’s exact etiology remains unclear, although it is frequently associated with chronic urinary obstruction and infections within the urinary tract. Superinfections such as Escherichia coli, Proteus mirabilis, and occasionally Pseudomonas species typically cause XGP. Documented cases of Raoultella ornithinolytica (R. ornithinolytica) infections in humans, particularly within the urinary tract, are limited. However, advancements in diagnostic techniques are expected to increase the detection of such rare pathogens. To the best of our knowledge, currently, there is no evidence in the literature indicating that this pathogen is responsible for XGP. We present a case of XGP in which we isolated R. ornithinolytica and discuss its treatment in the current literature.

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DOI: 10.3897/folmed.67.e152245

Authors: Savaş Gegin, Ahmet Cemal Pazarlı, Burcu Özdemir, Levent Özdemir, Esra Arslan Aksu

Abstract: Aim: This study aimed to identify bacterial pathogens causing chronic obstructive pulmonary disease (COPD) exacerbations and asthma attacks by evaluating nasopharyngeal swabs tested by polymerase chain reaction (PCR) and simultaneous sputum cultures from hospitalized patients, and to assess the contribution of PCR to causative agent identification. Materials and methods: Patients hospitalized with COPD exacerbations or asthma attacks from September 2022 to May 2023 were included. Bacterial pathogens were evaluated using PCR on nasopharyngeal swab samples, with simultaneous sputum culture results recorded. Analyzed pathogens included Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, Bordetella pertussis, Legionella pneumophila, and Chlamydia pneumoniae. Frequencies of pathogens detected by PCR and culture were compared. Results: The study included 911 patients. Nasopharyngeal swabs and simultaneous sputum cultures were obtained from 448 patients with COPD exacerbations and 127 patients with asthma attacks. In COPD exacerbations, H. influenzae was detected in 52 (8.7%) patients and S. pneumoniae in 32 (5.3%) by PCR, compared to 2 (0.4%) and 3 (0.7%) patients by sputum culture, respectively. In asthma attacks, H. influenzae was detected in 20 (6.5%) patients and S. pneumoniae in 11 (3.5%) patients by PCR, with S. pneumoniae detected by sputum culture only in 1 (0.8%) patient. H. influenzae and S. pneumoniae were significantly higher in COPD exacerbations and asthma attacks using PCR (p<0.05). Conclusion: PCR may detect bacterial pathogens in COPD exacerbations and asthma attacks more effectively than sputum culture within the context of this study.

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DOI: 10.3897/folmed.67.e146769

Authors: Ali Mohammed Ali Al-Nuaimi

Abstract: Aim: To investigate the value of the hematological indices to differentiate bacterial vaginosis (BV) from vulvovaginal candidiasis (VVC) and predict treatment response. Materials and methods: This nested case-control study included 390 women divided into three groups: healthy women, women diagnosed with BV, and women diagnosed with VVC. Additionally, two groups (BV and VVC) were treated and followed prospectively until cured. Demographic data, blood indices, and high-sensitivity C-reactive protein (hsCRP) were obtained from the women. Results: hsCRP and neutrophil-lymphocyte ratio (NLR) showed the best diagnostic utility to predict BV with AUC=0.721 and 0.735, respectively. hsCRP showed the best specificity (99.23%), while NLR showed the best sensitivity (82.31%) to differentiate BV. Regarding percentage change after treatment, NLR showed a higher reduction percentage in the BV group (−27.41±8.151%) than VVC (0.158±5.804%). Conclusions: NLR is an efficient diagnostic instrument for distinguishing individuals with bacterial vaginosis from those with vulvovaginal candidiasis. Its diagnostic reliability is comparable to more regularly used markers such as WBC and hsCRP. Both NLR and PLR are good predictors of clinical response to treatment in bacterial vaginosis.

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DOI: 10.3897/folmed.67.e144949

Authors: Thuraya K. Alwandawi

Abstract: Introduction: Periodontitis and apical periodontitis are multifactorial inflammatory diseases involving microbial activity and host responses that lead to tissue destruction. Biomarkers such as receptor activator of nuclear factor-kappa B (RANK), its ligand (RANKL), and the osteoprotegerin (OPG) system in gingival crevicular fluid (GCF) have been investigated for their diagnostic and prognostic roles in these conditions. Aim: This study evaluates these biomarkers’ levels to differentiate between stage I and stage III periodontitis, and healthy controls. Materials and methods: This cross-sectional study included 90 participants divided into three groups: stage I periodontitis, stage III periodontitis, and healthy control. GCF samples were collected from all participants in this study to measure the immunomarkers using ELISA. Results: The result revealed significantly higher levels of RANKL and OPG in stage I periodontitis compared to stage III periodontitis and controls. Additionally, we observed a significant difference between the study groups in the RANK/OPG and RANKL/OPG ratios, with stage I periodontitis showing the highest ratios. Conclusion: This study demonstrated that the levels of receptor activator of nuclear factor-kappa B (RANK), its ligand (RANKL), and osteoprotegerin (OPG) in the gingival crevicular fluid (GCF) can serve as valuable biomarkers for distinguishing between stage I and stage III periodontitis. The results showed a significant increase in RANKL and OPG levels in stage I periodontitis compared to stage III and control groups. Moreover, the RANK/OPG and RANKL/OPG ratios were significantly higher in stage I periodontitis, indicating their potential as diagnostic indicators.

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DOI: 10.3897/folmed.67.e143137

Authors: Esra Hassan Abd Ali, Suzan Mohammed Abdul Raheem, Hussain Owaid Muhammed, Alzahraa Jabbar Jassim, Abdullah J. Jasem

Abstract: Introduction: A substantial body of research has underscored the intricate nature of diagnosing oral disorders in conjunction with chronic inflammatory diseases. Aim: Multiple sclerosis (MS) and rheumatoid arthritis (RA) are chronic autoimmune diseases, which are usually difficult to distinguish in the early stage of the diseases. The objective of this study was to explore the differences of immune mechanism and diagnostic markers through bioinformatics analysis of the pro-inflammatory cytokine’s markers (IL-1β, IL-6, and TNF-α) to evaluate the role of immunological markers in patients with MS and RA with oral diseases. Materials and methods: This study enrolled 54 patients with oral disorders and chronic inflammatory diseases admitted to our hospital between January 2020 and December 2022, among 587 patients who had MS or RA and 50 healthy controls without oral disorders, with age, sex, and familial and genetic factors matching. Oral disorders were diagnosed and staged according to the method of dental examination. Blood (IL-1β, IL-6, and TNF-α) levels were measured using ELISA to detect chronic inflammatory diseases. Results: Important changes were found in RA and MS patients in terms of their age at onset of disease: RA patients exhibited a higher average age of onset (47.29 years) compared to MS patients (30.56 years), with both conditions showing a female predominance. Genetic factors did not differ significantly between the two conditions. Patients with both chronic inflammatory diseases and oral disorders had elevated levels of the studied markers (IL-1β, IL-6, and TNF-α) compared to those without oral disorders, indicating a substantial impact of oral diseases on immunological responses. Conclusions: RA typically affects older individuals, while MS onset occurs at a younger age with a higher female prevalence. Xerostomia was more common in RA, while oral candidiasis was more common in MS. Both active MS and patients with oral disorders exhibit high concentrations of IL-1β, IL-6, and TNF-α markers. These outcomes may have inferences for understanding the immune reaction and inflammation in these conditions.

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DOI: 10.3897/folmed.67.e137670

Authors: Ankit Shah, BC Sikkerimath, Yash Merchant, Santosh Gudi, Satyajit Dandagi, Dinesh Shah

Abstract: Aim: Maxillofacial space infection refers to infections in the potential spaces and fascial planes of the maxillofacial region. The primary objective was identifying predictive variables associated with increased hospital stay in patients with odontogenic maxillofacial space infections. Materials and methods: A retrospective chart review of all patients treated for odontogenic maxillofacial space infections from January 2001 to December 2012 at the P.M.N.M. Dental College and Hospital, Bagalkot, was conducted. Results: Out of 141 patients identified, 59.6% were females, and the mean age of our study group subjects was 36.81±15.76 years. 9.93% of the patients had diabetes, and the most common space involved was the buccal space. The mean white blood cell (WBC) count was 12329.93 cells/mm3, and the most common bacteria isolated were Staphylococcus aureus. The average length of hospital stay was 6.06±2.96 days. Space involvement, severity of infection (presenting WBC count in the CBC), and pre-morbid medical status increased the length of in-patient stay post-operatively with a statistical significance. Conclusion: The results of our retrospective study noted a higher prevalence of maxillofacial space infections due to odontogenic etiology in the age group of 31-50 years with the buccal space being implicated the most. The predictors associated with an increased length of hospital stay were spaces involved, treatment regimen, severity of infection (indicated by presenting WBC count in the CBC), and pre-morbid medical status.

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DOI: 10.3897/folmed.66.e136356

Authors: Ehab Qasim Talib, Ghada Ibrahim Taha, Dhuha Mahmood Ali, Sahar Hashim Al-Hindawi, Fadia Abd Almuhsin Al-Khayat, Israa Amer Hasan

Abstract: In the field of implantology, peri-implantitis is still a common complication of implant failure. Similar to periodontal disease, this kind of pathological condition is characterized by inflammation of the tissues surrounding dental implants or fillings. The sources of infection have been shown to be chronic periodontitis and poor maintenance of the communion. A thorough examination of the intricate components of peri-implantitis was sought in this review in order to identify common characteristics of the disease with regard to bacteria, biofilm formation, host immunological responses, diagnostic tools, and therapeutic treatments. The aim of this study was to provide a detailed overview of the different bacterial species associated with peri-implantitis, a clinical condition similar to periodontitis, characterized by a higher prevalence of staphylococci and enteric bacteria. The study underscores the importance of employing sophisticated diagnostic methods like cone beam computed tomography. It covers a range of therapeutic approaches including surgical and non-surgical techniques as well as strategies stressing host-modification and photodynamic treatment. The study was conducted using pertinent publications from scientific databases, including Scopus, Google Scholar, PubMed, and Web of Science. We searched these databases using the following terms: periodontitis, microbial, dental implants, peri-implantitis, and biofilm formation.

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DOI: 10.3897/folmed.66.e124015

Authors: Petya Argirova, Angel Todev, Yordan Kalchev, Simona Zlatanova, Mariyana Stoycheva-Vartigova

Abstract: COVID-19 presents with respiratory symptoms and signs in the majority of cases. The central nervous system can be affected directly or indirectly, which is demonstrated by a number of neurological abnormalities and complications. The aim of this study is to present a clinical case of SARS-CoV-2-associated encephalitis and highlight the severity of this neurological illness over the course of COVID-19. Etiological diagnosis methods include examination of the nasopharyngeal swab and cerebrospinal fluid by PCR. A 45-year-old man with fever, altered consciousness, and tonic-clonic seizures was admitted to the Clinic of Infectious Diseases, St George University Hospital, Plovdiv. The diagnosis of COVID-19 encephalitis is based on typical clinical and laboratory data, positive SARS-CoV-2 PCR, and exclusion of other likely causative agents into the cerebrospinal fluid. The patient was discharged two weeks after admission without neurological sequelae. The case confirms the clinical variety of COVID-19 and the possibility of severe neurological manifestations. Encephalitis is a rare but potentially life-threatening condition. Physicians should be aware of encephalitis in SARS-CoV-2 patients with neurological symptoms.

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DOI: 10.3897/folmed.66.e111548

Authors: Rada Gancheva, Joana Pozharashka, Atanas Koundurdjiev, Milena Nikolova-Vlahova, Petya Yankova, Liubomir Marinchev

Abstract: Pityriasis lichenoides is a rare inflammatory skin condition presenting with diffuse red-brown papules with evolution polymorphism and mica-like crust on older skin lesions. We present a 60-year-old female patient with pityriasis lichenoides chronica that manifested ten days after streptococcal pharyngitis. Initially, palpable purpura appeared on the lower extremities and later, erythematous-squamous papules and plaques appeared at the site of the palpable purpura and on the upper limbs and trunk. The patient had no history of hematological malignancy, viral hepatitis, kidney involvement, systemic rheumatic disease, or ANCA-associated vasculitis. After administration of methylprednisolone 20 mg for one month and an antimalarial agent (hydroxychloroquine 200 mg, 1 tablet bid) for three months, the skin lesions subsided without recurrence.

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DOI: 10.3897/folmed.66.e124561

Authors: Sahar Mohammadi Baladezaee, Mehrdad Gholami, Elham Amiri, Hamid Reza Goli

Abstract: Aims: Pseudomonas aeruginosa plays an important role in hospital infections caused by several virulence factors, such as elastase and proteases. This study aimed to evaluate the prevalence of LasA, LasB, and PIV genes, encoding these enzymes, in clinical isolates of P. aeruginosa. Materials and methods: One hundred clinical isolates were collected from patients admitted to educational and therapeutic hospitals of Mazandaran Province, North Iran. The isolates were identified by the standard microbiological and biochemical tests. The bacterial DNA was extracted by the alkaline lysis method, and the presence of relevant genes was detected using the PCR method. The data were analyzed using SPSS v. 23 and the chi-square test. A p-value <0.05 was considered statistically significant. Results: In 100 clinical isolates of P. aeruginosa, the LasA, LasB, and PIV genes were presented with a frequency of 97%, 96%, and 97%, respectively. Of the total number of samples, 39 patients were female and 61 were male. Also, the majority of the patients were between 61 and 70 years old. Conclusion: LasA, LasB, and PIV are highly prevalent in clinical isolates of P. aeruginosa, indicating the importance of these genes as key virulence factors in P. aeruginosa pathogenicity in this region.

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DOI: 10.3897/folmed.66.e109225

Authors: Igor Vasilev, Igor Mamenko, Roman Simonov, Tatiana Novitskaya, Viacheslav Zhuravlev, Petr Yablonskiy

Abstract: The diagnosis of intrathoracic non-tuberculous mycobacteriosis (NTM) is challenging. We report a case of a pediatric pulmonary NTM with endobronchial lesion and lymphadenitis in a child with HIV infection diagnosed by bronchoscopic biopsy, EBUS-TBNA and probe-based confocal laser endomicroscopy (pCLE). The pCLE showed a large number of highly fluorescent cells and zones of density and disorganized elastin fibers at alveolar areas. A combination of diagnostic endoscopic procedures is required to establish the diagnosis of NTM.

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DOI: 10.3897/folmed.66.e113356

Authors: Steliyan Petrov, Hristo Taskov, Marianna Murdjeva

Abstract: The COVID-19 pandemic has left a lasting impact on global health, challenging communities, healthcare systems, and researchers worldwide. As we navigate this unprecedented crisis, this paper embarks on a multifaceted exploration of the pivotal role played by natural killer (NK) cells in the context of COVID-19. A significant portion of this paper is devoted to dissecting the nuanced role that NK cells assume in the context of COVID-19. From the initial acute infection to post-recovery immunity, NK cells emerge as critical players. We scrutinize the activation and dysregulation of NK cells during SARS-CoV-2 infection, shedding light on their potential contribution to disease severity. Moreover, we explore the fascinating landscape of post-COVID immunity, where NK cells are known to interact with adaptive immune responses, providing a foundation for long-term protection. In light of their central role, we investigate therapeutic strategies targeting NK cells in COVID-19 management, presenting an overview of current research efforts and their promise in mitigating disease progression. Lastly, we draw attention to research gaps, emphasizing the need for further investigation into NK cell dynamics during COVID-19. These gaps represent opportunities for advancing our understanding of NK cell biology and, by extension, enhancing our strategies for combating this global health crisis. This comprehensive exploration not only highlights the intricate interplay between NK cells and the COVID-19 pandemic but also underscores the importance of these innate immune warriors in shaping both the acute response and long-term immunity, ultimately contributing to the broader discourse surrounding the pandemic’s pathophysiology and therapeutic approaches.

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DOI: 10.3897/folmed.65.e98732

Authors: Bistra Dobreva-Yatseva, Fedya Nikolov, Ralitsa Raycheva, Albena Botushanova, Maria Koleva, Mariya Tokmakova

Abstract: Infective endocarditis (IE) is a difficult-to-diagnose provocative disease that causes significant morbidity and mortality. The first-line imaging test for the diagnosis of IE is echocardiography. However, in cases of prosthetic IE or IE associated with intracardiac devices, its sensitivity is limited. A new diagnostic tool, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT), improves diagnosis in these difficult cases. The most recent European guidelines for IE (2015) include this imaging modality as a primary diagnostic criterion. We present a case of culture-negative prosthetic IE diagnosed with 18F-FDG PET/CT.

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DOI: 10.3897/folmed.65.e90054

Authors: Vasiliki Papadatou, Stylianos Tologkos, Theodora Deftereou, Triantafyllos Alexiadis, Olga Pagonopoulou, Christina-Angelika Alexiadi, Panagiota Bakatselou, Sadik Tzem Chousein Oglou, Grigorios Tripsianis, Achilleas Mitrakas, Maria Lambropoulou

Abstract: Introduction: Parvoviruses are DNA viruses of small size. There have been a number of reports indicating the possible effects of B19 infections during pregnancy. These effects include spontaneous abortions, stillbirth, fetal damage, and quite often, fetal anemia with hydrops fetalis. Aim: The aim of this study was the correlation of Epstein-Barr virus (EBV) and parvovirus-B19 infections with inflammation levels in placental tissue coming from spontaneous abortions and elective terminations cases. We also investigated whether viral presence could cause spontaneous abortions by associating the expression levels of inflammatory markers with adverse pregnancy outcomes. Materials and methods: One hundred ninety-four placental samples were used, 152 included in the study group coming from spontaneous abortions while 42 controls were used from cases of elective terminations. Hematoxylin and eosin (H&E) staining was performed to investigate morphological changes in the tissues, and then indirect immunohistochemistry to evaluate the expression of TNF-α, IL-6, IL-1α, B19, and EBV. Statistical analysis was performed using SPSS v. 19.0 (IBM). Results: Higher inflammation levels were observed with statistical significance in the spontaneous abortions group (p<0.001) and they were correlated with statistical significance with B19 or EBV presence (p<0.001). Viral presence was only found in the spontaneous abortions group. Both simple and multiple logistic regression confirmed that viral presence was an independent prognostic factor for high expression of all inflammatory biomarkers with statistical significance (p<0.001). Conclusions: Our results clearly indicate a specific pattern. Viral presence can deregulate inflammatory processes in the maternal-fetal environment and thus work as a trigger for spontaneous abortions.

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DOI: 10.3897/folmed.65.e90402

Authors: Caner Baran, Abdullah Talha Akan, Veysel Sezgin, Ahmet Boylu, Çiğdem Arabaci, Emre Can Polat, Alper Ötünçtemur

Abstract: Introduction: Urinary tract infections are the most common bacterial infections in the older population. Aim: This study aims to determine the impact of the isolated pathogen from urine culture on the estimated survival time of elderly male patients. Materials and methods: We conducted a retrospective cross-sectional study to evaluate the male patients with pathogenic growth in their urine culture tests. We included in the study only male patients aged 80 years or over with positive urine culture tests for pathogenic growth. Urine samples were collected from either first clean-catch midstream urine or from the urinary catheters. Bacterial growth of ≥105 colony-forming units/mL (CFU/mL) in the culture was considered significant. For comparison of the survival time, five groups were created according to the pathogens identified in the urine culture. Results: Between February 2014 and December 2020, there were 1133 patients that met the study criteria. The most common pathogen was Escherichia coli with a rate of 29.5%. The median overall survival time was 4 months. The longest and shortest median overall survival times for the E. coli group and the fungi group were 17.4 months and 0.4 months, respectively (p<0.001). While being in the ICU is the most important risk factor for mortality in this elderly cohort, the statistical analysis showed that being infected with fungi carries a 1.57-fold increased risk of mortality compared with the E. coli infection (p<0.001). Conclusions: The aging of the population requires evaluation of the diseases that are frequently encountered in advanced age. Our study showed that the causative pathogen of the urinary tract infection might have an impact on overall survival time in the senior population.

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DOI: 10.3897/folmed.65.e108153

Authors: Rada M. Markova, Iren S. Tzotcheva, Penka Perenovska, Atanas Mangarov, Lubomira Nikolaeva-Glomb, Veselin Hadjiev

Abstract: Introduction: Acute upper respiratory tract infections (AURTIs) are associated with a significant burden on society attributed to medical care and loss of productivity. Novel therapies that are able to shorten disease duration, while providing symptom relief and being well tolerated, are an unmet medical need. Aim: The main objective of this trial was to investigate the efficacy and safety of Aviron Rapid, a dietary supplement containing andrographolide, proprietary spirulina, and humic acid, in the management of AURTIs in adolescents and children. Materials and methods: This randomized, double-blind, placebo-controlled trial was conducted between January 2020 and March 2020 in 85 general practitioner practices in Bulgaria. Adolescents (13–17 years) and children (5–12 years) with a clinical diagnosis of AURTI were randomly assigned to receive standard symptomatic therapy + Aviron Rapid or placebo for 5 and 7 days, respectively. The primary endpoints of this trial were the number (and percentage) of clinically recovered patients and the mean disease duration. Results: In total, 380 adolescents and 401 children were enrolled in 2 age cohorts and randomly assigned to treatment with Aviron Rapid or placebo. The percentage of patients meeting the criteria for clinical recovery was significantly higher in the Aviron Rapid group compared with the placebo group from 24 and 48 hours after initiation of treatment in adolescents and children, respectively. Aviron Rapid treatment significantly reduced the duration of disease, of fever, and of antipyretics intake in both adolescents and children. When compared to placebo, a significantly higher percentage of adolescents and children on Aviron Rapid achieved a persistent decrease in temperature of less than 37°C as soon as 24 hours after starting treatment. Overall, a low number of adverse events was reported and no major differences in the incidence of individual adverse events were observed between the two treatment groups in both cohorts. Conclusions: This clinical trial demonstrated the efficacy of Aviron Rapid in the management of acute upper respiratory tract infections in adolescents and children. Aviron Rapid treatment rapidly increased the number of clinically recovered patients and reduced overall disease duration and duration of symptoms, in particular fever, while being well tolerated. Trial registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12221500. Retrospectively registered on 29 March 2022. [https://doi.org/10.1186/ISRCTN12221500]

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DOI: 10.3897/folmed.65.e79966

Authors: Andreana Angelova, Mariya Atanasova, Kostadin Ketev, Zeyra Halil, Ivanka Paskaleva, Gergana Lengerova, Teodora Dimcheva, Neli Korsun, Mariana Murdjeva

Abstract: The Coronavirus Disease 2019 (COVID-19) caused by a novel coronavirus (SARS-CoV-2) affects mainly older adults. Those with comorbidities are at a higher risk of severe disease and even death. The symptomatic infection rate of children is lower, manifestations are milder, and severe forms are scarce. We present here two children with severe COVID-19 and a respiratory syncytial virus, with the goal of emphasizing the possibility of coinfection with a severe course and a different result. The microbiological diagnosis was made using multiplex PCR. This assay not only provided an early and accurate diagnosis but also aided in the implementation of contact precautions. Further research should be done to determine the influence of coinfection on the clinical course and outcome of pediatric patients.

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DOI: 10.3897/folmed.65.e80599

Authors: Yana Todorova, Radoslava Emilova, Vladimir Milanov, Elizabeta Bachiyska, Yuliana Atanasova, Ana Baikova, Maria Nikolova

Abstract: Abstract Introduction: The need for biomarkers predicting the course of MTB infection and the necessity of specific therapy are well recognized. Recent data point to the role of cytokines and lipid mediators in protective immunity against tuberculosis. Aim: We evaluated the balance between cytokines, and eikosanoids as a possible prognostic indicator in MTB infection. Material and methods: The induced expression of effector and regulatory cytokines IFN-γ, TNF-α, IL-2, IL-17, IL-6, and IL-10 was measured in relation to the lipid mediators PGE2 and LXA4 in active TB infection (ATB, n=15) before and after therapy (ATB-T, n=6), established latent infection (LTBI, n=22), recent contacts of ATB (RC, n=12), and healthy controls (n=11) A flow cytometry microarray (CBA, BD Biosciences) and quantitative ELISA (SunRed Tech) were employed. Results: The regulatory cytokines (RC) were characterized by a high potential for IL-17 and Th1 cytokine secretion, combined with low IL-6 expression, while ATB donors had a partially preserved TNF-α potential, and higher IL-6 expression. The PGE2-to-LXA4 ratio discriminated between situations with high bacterial load (ATB), and contained infection (LTBI, ATB-T), and defined clearly cut subgroups among RC and ATB donors. Conclusions: Our results suggest that increased PGE2/LXA4 ratio coupled with high induced IL-10 level indicates infection after a recent contact. In the settings of ATB, increased ratio and low TNF-α level point to inefficient granuloma formation in the settings of ATB.

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DOI: 10.3897/folmed.65.e79869

Authors: Radka T. Komitova, Ani Kevorkyan, Petur Vasilev, Elitsa Golgocheva-Markova, Maria Atanasova

Abstract: The COVID-19 pandemic has exploded since the first cases were reported in Wuhan in December 2019, engulfing the globe. Many infected individuals are asymptomatic or have a mild or moderate disease. A subset of people with advanced age, the immunocompromised and those with chronic diseases, are prone to serious-to-critical illness. We report a fatal case of metastatic colorectal cancer survivor who developed COVID-19 after clinically reactivated hepatitis B virus (HBV) due to chemotherapy. The patient’s COVID-19 illness was supposed to be related to her recent medical evaluation. Although being diagnosed with chronic HBV infection for decades, she was not treated with nucleotide analogue and the possibility to preclude HBV reactivation was missed. Moreover, infectious control practices must be draconian in order to save such a fragile population from infections.

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DOI: 10.3897/folmed.65.e76245

Authors: Presiyana Nyagolova, Mitko Mitkov, Lyubomir Sapundzhiev

Abstract: Autoimmune polyglandular syndromes (APS) are rare disorders characterized by the coexistence of endocrine and non-endocrine dysfunctions mediated by autoimmune mechanisms. Autoimmune polyglandular syndrome type 1 is defined as coexistence of chronic mucocutaneous candidiasis, hypoparathyroidism, and autoimmune adrenal insufficiency. Addison’s disease as the obligatory component is potentially life threatening. Herein, we demonstrate a case of a 44-year-old woman with APS-1 (hypoparathyroidism, adrenal insufficiency, hypergonadotropic hypogonadism) and SARS-CoV-2-induced adrenal crisis. The patient presented with the typical manifestations of hypotensive shock, electrolyte disturbances of hyponatremia and hyperkalemia, and hypoglycaemia. Our case report illustrates the increased risk of severe course of COVID-19 in APS-1 syndrome patients along with heightened exposure to medical complications. The case reinforced the significance of a timely diagnosis, appropriate treatment, and education of patients with such a rare condition like APS-1.

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DOI: 10.3897/folmed.65.e72203

Authors: Hasan Burnusuzov, Ivan Yankov, Kostadin Ketev, Mariana Murdjeva

Abstract: Cytomegalovirus is widely spread worldwide, and it is not uncommon for it to complicate the congenital human immunodeficiency virus (HIV) disease as an acquired or congenital coinfection. However, the association of the two infections is not common amongst infants with primary immune deficiencies. We describe a case of a 6-month-old infant with acquired cytomegalovirus and HIV infections, diagnosed in the course of the patient’s clinical and laboratory workup for a presumed primary immunodeficiency. To date, this is the first reported case of such a combination in a child from Bulgaria.

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DOI: 10.3897/folmed.65.e73081

Authors: Petar Vassilev, Ekaterina Zaytseva, Raina Ardasheva, Valentin Turiyski

Abstract: Aim: The present study was conducted in an attempt to find possible direct mechanisms of action of Clostridium difficile toxins A and B (TCdA and TCdB) on contractility of isolated rat intestinal smooth muscles, as the contractive pathways affected by the toxins and responsible for motility disorders remain unclear. Materials and methods: Adult male Wistar rats were used in our experiments. Longitudinal smooth muscle (SM) preparations of proximal colon were isolated and their contractile activity was isometrically registered. The samples were mounted in tissue baths and exogenously treated with acetylcholine (ACh), serotonin (5-HT), dopamine, norepinephrine, TCdA and TCdB. The potential of TCdA and TCdB to affect the action of these mediators on SM activity was examined. Results: The experiments have shown that exciting action of ACh and 5-HT on colonic contractility is enhanced by TCdA rather than TCdB. Conversely, relaxing effect of dopamine and norepinephrine on contractile activity of colonic SM is under impact of TCdB but not TcdA. TCdA has a stronger direct effect on in vitro SM sensitivity to ACh and 5-HT than TCdB. Conclusions: TCdA and TCdB affect directly the contractile reactivity of isolated rat colon smooth muscle. TCdA has a stronger direct effect on smooth muscle sensitivity to acetylcholine and 5-HT than TCdB. Such a trend has not been established for dopamine and norepinephrine.

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DOI: 10.3897/folmed.64.e72257

Authors: Yordan Kalchev, Marianna Murdjeva

Abstract: The incidence of infections affecting the central nervous system has increased in recent years, making neuroinfections a current global health problem. The central nervous system is quite well protected from the external and internal environments, although it is susceptible to infection by a wide variety of pathogens. The etiological diversity further complicates the management of such infections because it is important to identify correctly the specific cause in order to choose the most appropriate antimicrobial therapy. Diagnosis is made not only based on clinical and epidemiological data but also on the results of clinical laboratory and microbiological examination of cerebrospinal fluid. This article aims to review current microbiological methods in the diagnosis of acute central nervous system infections and help healthcare providers to recognize their advantages and limitations in order to manage their patients appropriately.

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DOI: 10.3897/folmed.64.e68987

Authors: Neli Vilhelmova, Ivanka Nikolova, Kaloyan D. Georgiev, Iliya J. Slavov

Abstract: Introduction: Based on traditional medicine, many countries use various plant products (fruits, leaves and other plant parts) as food supplements or in the form of tea. The use of these plant sources has been established through the years of use and the proven benefits of their ingredients to improve human health. Aim: In the present study, we have focused on the effect of Lycium barbarum fruit extract and methylxanthines isolated from Pu-erh (MXP) and Bancha (MXB) tea leaves on Herpes simplex virus type 1 (HSV-1), poliovirus 1 (PV1) and coxsackievirus B1 (CVB1) virus in vitro. Materials and methods: We used in vitro antiviral and virus attachment assays to determine the effects of the three extracts we studied. Results: None of the extracts showed significant inhibition of replication of the three treated viruses but a remarkable inhibitory effect on extracellular virions of HSV-1 was exhibited 30 minutes after exposure, especially by the Lycium barbarum extract. The inhibitory effect of the three extracts on the level of adsorption of the HSV-1 to sensitive cells (MDBK) was also significant, with the most pronounced effect of the MXP. The protective effect of the extracts against herpes infection on healthy cells was also determined, the MXP showing the most notable effect. Conclusions: The three studied extracts can be used effectively in the treatment of herpes infections, as well as in infections with other enveloped viruses.

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DOI: 10.3897/folmed.64.e65957

Authors: Ralitsa Raycheva, Ani Kevorkyan, Yordanka Stoilova

Abstract: Introduction: Varicella is an acute, highly contagious disease, characterised by generalised vesicular exanthema caused by the initial infection with varicella zoster virus (VZV) which usually affects children aged 2 to 8 years. Aim: To analyse the changes of varicella incidence in Bulgaria over the period of 1928–2019. Materials and methods: The time series analysis is based on the official data for varicella incidence (per 100,000) in Bulgaria for ninety-two years (1928–2019), obtained from three major sources. We utilized the method to construct a time series model of overall incidence (1928–2019) using time series modeller in SPSS v. 25. We followed all three steps of the standard ARIMA methodology to establish the model – identification, parameter estimation, and diagnostic checking. Results: Stochastic scalar time series modelling of the varicella incidence from 1928 to 2019 was performed. The stochastic ARIMA (0,1,1) was identified to be the most appropriate model. The decomposition of varicella incidence time series into a stochastic trend and a stationary component was reasoned based on the model defined. In addition, we assessed the importance of the long-term and immediate effect of one shock. The long-term forecast was also under discussion. Conclusions: The ARIMA model (0,1,1) in our study is an adequate tool for presenting the varicella incidence trend and is suitable to forecast near future disease dynamics with acceptable error tolerance.

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DOI: 10.3897/folmed.64.e64004

Authors: Vessela V. Ouzounova-Raykova

Abstract: Abstract The green nail syndrome is characterized by discolouration of the nail plate frequently accompanied by chronic paronychia and onycholysis. The cause could be either bacterial or fungal infection. A 24-year-old woman presented to the clinic with a history of discolouration of the nail plate and bed accompanied by onycholysis. Scrapings from the nail were taken twice, microscopically examined, and cultured on media for isolation and identification of bacteria and fungi. The first sample gave positive results for Enterococcus spp. After treatment and a lack of complete recovery of the nail, second sample was taken and subjected to the same tests. This time Fusarium infection was detected. Additional treatment was performed and the nail’s plate and bed were successfully treated.

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DOI: 10.3897/folmed.64.e63624

Authors: Ivva Philipova, Viktoryia Levterova, Ivan Simeonovski, Todor Kantardjiev

Abstract: Introduction: Mycoplasma genitalium is an established cause of sexually transmitted infections in men and women. Current guidelines recommend azithromycin and moxifloxacin as first- and second-line treatment, respectively. However, azithromycin treatment failure has been increasingly reported. The aim of this study was to determine the efficacy of azithromycin and alternative antibiotic regimens in a prospective cohort of M. genitalium-positive patients, and macrolide resistance mutations associated with azithromycin failure. Materials and methods: Consecutive eligible M. genitalium-positive patients attending the National Center of Infectious and Parasitic Diseases in Sofia, Bulgaria between 1 January 2018 and 31 December 2020 were treated with azithromycin and retested by polymerase chain reaction 21-28 days after completion of the treatment. Cure was defined as M. genitalium-negative result on the test of cure. Cases failing azithromycin were treated with moxifloxacin and retested another 21-28 days after treatment. Pre- and post-treatment samples were assessed for macrolide resistance mutations by conventional DNA sequencing. Results: Of 21 patients treated with azithromycin, 11 (52.4%) were cured. Pre- and post-treatment macrolide resistance mutations were detected in 10 (47.6%) patients, and all of them failed azithromycin. Moxifloxacin was effective in all cases failing azithromycin; and all were M. genitalium-negative at the test of cure after moxifloxacin treatment. Conclusions: In this study a high azithromycin failure rate (47.6%) in an M. genitalium-positive cohort in association with high levels of pretreatment macrolide resistance was reported. Moxifloxacin was highly effective in treating macrolide-resistant infections. These findings necessitate implementation of new diagnostic and therapeutic strategies such as sequential antimicrobial therapy for M. genitalium guided by a macrolide-resistance assay.

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DOI: 10.3897/folmed.64.e62365

Authors: Yavuz Güler, Akif Erbin, Tahsin Gozdas

Abstract: Introduction: Outbreaks caused by microorganisms contaminating the inside of rigid ureteroscopes are extremely rare. Some of these outbreaks, especially those caused by multidrug-resistant (MDR) infections, can cause serious problems, even death. Among these serious infections, we have no data about Klebsiella pneumoniae outbreaks caused by rigid ureteroscopes and their management and consequences. Aim: We aimed to report the outcomes of an outbreak of rapidly developing MDR K. pneumoniae urosepsis linked to rigid ureteroscopy (URS). Materials and methods: Data for 68 patients who had ureteroscopic lithotripsy (URS-L) operations using the same ureteroscope were retrospectively reviewed. Among them, 17 patients with postoperatively developing urosepsis were included in the study. Samples were taken from the operating room, camera heads, endoscopes, and ancillary instruments for culture workup. K. pneumoniae was produced in a swab culture obtained from the water inlet channel of the ureteroscope. Results: All patients had sepsis signs that developed within hours (2-7 hours). MDR K. pneumoniae was detected in the urine cultures of all patients. It was sensitive only to amikacin, tigecycline, colistin, and netilmicin. All patients were treated with tigecycline (100 mg intravenous daily). It was observed that K. pneumoniae growth continued without any symptoms in the first and fourth weeks of follow-up in 4 patients. These patients were accepted as colonization; no additional treatment was given. Conclusions: In the case of rapidly developing urosepsis after the URS procedure in a patient, instruments, devices, and endoscopes should be immediately checked for contamination to prevent the emergence of an outbreak.

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DOI: 10.3897/folmed.64.e61406

Authors: Androniki Stavridou, Despoina Michailidou, Eleni Panagouli, Theodoros N. Sergentanis, Efthalia Tzila, Theodora Psaltopoulou, Maria Tsolia, Nikolaos Vlahos, Artemis Tsitsika

Abstract: Fear of COVID-19, especially in vulnerable groups such as pregnant women, created excessive concern leading to unexpected psycho-emotional consequences and a need to summarize the most recent knowledge about this topic. Therefore, we conducted a narrative review of the relevant literature, synthesizing data from available databases. According to the findings of this review, pregnant women during COVID-19 pandemic were more anxious and depressed mainly due to the fear of contacting the virus, the restrictive measures, and concerns about the health of their unborn children. The elevated stress levels in pregnant women due to the pandemic could represent risk factors for physical health complications. Thus, strategies including relaxation, mindfulness, acceptance, and positive attitude to COVID-19 should be promoted for pregnant women.

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DOI: 10.3897/folmed.63.e56786

Authors: Chaitali Lad, Ishan Panchal, Ashish Patel, Afzal Nagani, Vruti Parikh, Harnisha Patel, Bhargav Bhimani

Abstract: Introduction: Malaria is one of the varieties of fatal diseases caused by a protozoan parasite that is now considered to be the greatest global health challenge. A parasite of Plasmodium species triggers it transmitting the disease to humans by the bites of female Anopheles mosquitoes.Aim: To screen out designed molecules by molecular docking analysis and assess their pharmacokinetic properties using SwissADME. To synthesize the designed compounds. To characterize the synthesized compounds by TLC, melting point, IR spectroscopy, mass spectrometry, 1H NMR, and 13C NMR. To evaluate the synthesized compounds for antimalarial activity.Materials and methods: In silico analysis was performed with SWISSADME, and molecular docking was performed by AutoDock Vina version 4.2. In vitro antimalarial activity study was performed.Results: In-vitro studies of synthesized molecules showed that compounds C2 (IC50 1.23), C6 (IC50 0.48), C10 (IC50 0.79), and C14 (IC50 0.19) possess good antimalarial activity.Conclusions: 7-chloroquinoline-piperazine derivatives exhibited potential antimalarial compounds for pf-DHFR inhibitors.

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DOI: 10.3897/folmed.63.e56566

Authors: Faeze Abbaszadeh, Alka Hasani, Mohammad Ahangarzadeh Rezaee, Javid Sadeghi, Akbar Hasani, Mahin Ahangar Oskouee, Abolfazl Vahhabi

Abstract: Introduction: Acinetobacter baumannii infections are a growing public-health concern. The bacterium’s potentiality to acquire resistance to a number of commonly used antibiotics has turned it into a formidable pathogen.Aims: Molecular characterization of extensive drug resistant (XDR) typing of A. baumannii clinical isolates by polymerase chain reaction.Materials and methods: Thirty XDR A. baumannii were investigated for the presence of genes encoding carbapenemase resistance, biofilm capacity, autoinducer synthase, virulence and surface motility by polymerase chain reaction (PCR). Later, the isolates were typed by plasmid-based replicon (Rep) (PBRT) and trilocus sequence typing.Results: All 30 XDR A. baumannii strains displayed genes related to surface motility, autoinducer synthase, virulence determinant, biofilm related genes except PER, and bap, the frequency of which was 83.3% and 76.6%, respectively. Analysis of rep genes showed highest frequency of rep6 and rep2 genes, with frequency of 75% and 65%, respectively. All XDR A. baumannii strains belonged to SG I (European clone II) group.Conclusions: Our results show the extraordinary plasticity of XDR A. baumannii and suggest that the strains have gained endemicity in our hospital, which could be a great concern in the near future.

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DOI: 10.3897/folmed.63.e69003

Authors: Angel Uchikov, Lyubomir Paunov, Atanas Batashki, Emanuil Yordanov, Kiril Atliev, Chavdar Stefanov, Milena Sandeva, Peter Uchikov

Abstract: Introduction: The new coronavirus, SARS-CoV-2, provokes infection with different clinical presentation. It involves an asymptomatic condition, mild variants with fever and dry cough to severe pneumonia, adynamia and respiratory failure with lethal outcome. The fibrotic lung tissue after the inflammatory process is a background for development of a secondary pneumothorax. Although it rarely causes lethal outcomes in COVID-19 patients, pneumothorax requires early diagnosis and adequate treatment to prevent any complications and decrease mortality rate.Aim: The aim of this study was to analyse the results of surgical treatment of hospitalized COVID-19 patients with pneumothorax in terms of demographic data, concomitant diseases, complications, and outcome.Materials and methods: Longitudinal prospective study was carried out with 26 patients with pneumothorax as a result of SARS-CoV-2 infection. They were treated at the Intensive Care Unit of the Infectious Disease Clinic and at the Second Clinic of Surgery, St George University Hospital in Plovdiv over a 6-month period from September 2020 to February 2021.Results: Seventeen of the patients were men and nine – women. Twenty-four of all patients underwent thoracentesis and two of them had a video-assisted thoracoscopy. The mean age of the studied patients with pneumothorax and COVID-19 was 66.77±12.61 years, which shows that it is the patients of advanced age with concomitant diseases that are at a higher risk of serious complications and adverse outcome. Of the hospitalized 1245 patients with COVID-19, 385 (30.92%) passed away. Of all hospitalized patients with SARS-CoV-2, 26 (2.08%) developed pneumothorax. Sixteen of them (62%) passed away. The possibility of a lethal outcome for intubated patients increased more than twice.Conclusions: The pneumothorax as a complication of COVID-19 carries high mortality and severely worsens the prognosis for these patients.

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DOI: 10.3897/folmed.63.e56037

Authors: George Stoyanov, Deyan Dzhenkov, Lilyana Petkova

Abstract: Autopsy practice is one of the most well-defined procedures in medicine, with strict safety instructions in place to protect medical personnel from infectious agents. However, for various reasons, these precautionary measures are often overlooked. Herein we report two autopsy cases of patients who died during the COVID-19 pandemic and the national state of emergency declared in Bulgaria. One patient was a 77-year-old female who had a medical history of a viral respiratory tract infection in February 2020 but had not undergone any test. She had multiple comorbidities including hypertension, cerebral and cardiovascular disease, and type 2 diabetes. The other patient was a 53-year-old female with morbid obesity with previous medical history of malignancy, hypertension, and type 2 diabetes. Both patients were tested for COVID-19 during the autopsy. Gross and histological findings in both patients showed respiratory tract viral infection with severe complications, incompatible with life. The first patient had serous desquamative tracheitis, hemorrhagic pneumonia, pericarditis, meningitis, and acute necrotizing encephalitis. The second patient had serous tracheitis, interstitial pneumonia, and diffuse alveolar damage and pneumocyte cytopathic effect, the alveolar septi had undergone a fibrotic change, with serous meningitis and non-necrotizing encephalitis also noted histologically. Autopsy-wise, it is always important, against the backdrop of an epidemic, to use full precautionary measures and exclude epidemic strands in cases where gross findings are suggestive of a viral infection.

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DOI: 10.3897/folmed.63.e56124

Authors: Vera Zimina, Svetlana Degtyareva, Elena Beloborodova, Julia Klimova, Alexey Kravchenko

Abstract: Patients with HIV-infection diagnosed at late stages usually have significant immunosuppression and demand simultaneous antiretroviral therapy and treatment of opportunistic infections. The presence of HCV coinfection makes treatment even more challenging because of possible adverse effects and drug-drug interactions. HCV cure in such clinical situations not only prevents fibrosis progression, but can also enhance virologic and/or immunologic response to antiretrovirals and thus effective treatment of opportunistic infections. Thorough consideration of all existing diseases and drug interactions of the combined therapy makes simultaneous treatment of HIV, chronic hepatitis C, and opportunistic infections not only possible but the best way to improve outcomes in a complex clinical situation.

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DOI: 10.3897/folmed.63.e55496

Authors: Petar Vasilev, Mariya Ivanovska, Gergana Lengerova, Atanaska Petrova, Eli Hristozova, Marianna Murdjeva, Mariyana Stoycheva

Abstract: Most cases of acute diarrhea in adults are of infectious etiology, likely viral and self-limited. Among those with severe diarrhea, however, bacterial causes are responsible for most cases.Apart from the standard stool cultures, to increase the positive yield a novel multiplex molecular test can be performed simultaneously. The authors present a patient with recurrent diarrhea and detection of Aeromonas hydrophila by culturing and Rotavirus and Clostridioides difficile by multiplex molecular test. They discuss and justify which is the most likely actionable pathogen. Good communication between the physicians and interpretation on the multiple positive results in the context of clinical picture and the test employed were important for a better management and favourable outcome of the patient.

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DOI: 10.3897/folmed.63.e55017

Authors: Pavlina Peneva, Silviya Nikolova, Yana Bocheva

Abstract: Introduction: Sepsis is a significant cause of morbidity and mortality worldwide. Current clinical practice, however, lacks reliable diagnostic indicators for it and its prognosis.Aim: The present study aimed to investigate the efficacy of delta neutrophil index (DNI), which reflects the proportion of circulating immature granulocytes, in predicting infections and sepsis.Materials and methods: A prospective non-interventional single-center clinical follow-up study was performed in a Bulgarian ICU between January 1, 2017 and May 31, 2018. We analyzed adult patients: 45 patients met the sepsis criteria, as defined in SEPSIS-3, whereas 37 were infected patients fulfilling no criteria of sepsis. Logistic regression and Roc-curve analysis were used to evaluate the severity and prognostic value of DNI as a prediction marker in critically ill septic patients.Results: The results have shown that at DNI values of 1.4 there is 73% sensitivity and 87% specificity (AUC 0.764, 95% CI 0.650–0.878, p=0.0001) to assume the presence of sepsis. Additionally, DNI was significantly associated with the severity of the condition of patients, the organ dysfunction and the IL-8 marker.Conclusions: DNI may serve as a useful marker for early diagnosis of sepsis and could support decision making process regarding its treatment at an early stage of a disease development.

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DOI: 10.3897/folmed.63.e56228

Authors: Pavlina A. Peneva

Abstract: In 2019, the world faced another of the potentially deadly viruses affecting humanity. The new virus, COVID-19, was extremely virulent when it first appeared, with aggressive behaviour toward people unprepared at the time to deal with the infection.Months later, we already know much about its pathophysiology, but new and unknown pathophysiological aspects of the disease are revealed in time. The clinical picture is not unequivocal at times, with symptoms quite unlike those we have previously considered normal in respiratory infections tending to appear. There have been reports of an increase in the frequency of neoplasms or disease progression due to delayed treatment. Treatment of COVID-19 is still a mirage, and people are struggling with the implications for recovery, the health and economic crisis, and the psychological effects of traumatic stress.

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DOI: 10.3897/folmed.63.e54386

Authors: Ali Javadi, Mohamad Reza Pourmand, Javad Hamedi, Fatemeh Gharebaghi, Zohre Baseri, Abbas Morovvati, Razieh Mohammadzadeh, Seyyed Saeed Eshraghi

Abstract: Introduction: Bacterial natural products such as biosurfactants and surface-active agents are important compounds which exhibit many applications in the fields of medicine.Aim: The aim of the present study was to isolate and identify Nocardia strains with high biosurfactant production and antibiofilm ability.Materials and methods: In the present study, a biosurfactant producing Nocardia species was isolated and identified by a laboratory method. Nocardia species were initially screened and then tested for their ability to produce biosurfactant. The oil spreading test and the surface tension measurements showed that one strain was a biosurfactant producer. The strain with the best surface activity results was selected for further studies and identified by 16S rRNA gene sequencing method. Fourier transform infrared spectroscopy (FTIR) and compositional analysis proved a biosurfactant structure.Results: Oil spreading test and blue agar plate test confirmed biosurfactants and extracellular anionic glycolipids. E24% assay using olive oil revealed strong emulsifying characteristic of the extracted biosurfactant with 100% emulsifying strength. FTIR spectrum indicated the presence of aliphatic hydrocarbon chain (lipid) along with the polysaccharide portion, confirming the glycolipid nature of the biosurfactant. The stability of the biosurfactant produced in different conditions was significant. Increasing concentration of BS significantly inhibited Pseudomonas aeruginosa biofilm.Conclusions: N. coubleae can be a representative of the genus Nocardia for the production of biosurfactants with beneficial physicochemical properties.

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DOI: 10.3897/folmed.63.e54665

Authors: Silvia Palma, Laura Mazzoni, Maria Federica Roversi, Cecilia Botti, Daniele Monzani, Alberto Berardi, Elisabetta Genovese

Abstract: A 32-week preterm-born male with symptomatic congenital cytomegalovirus infection was treated with valganciclovir. He was also affected by congenital severe bilateral hearing loss and, unexpectedly, a normalization of the hearing threshold was reached at one year of age. The improvement of hearing level in relationship with both the late development of the auditory system and the administration of antiviral therapy is discussed. This case also highlights the importance of early diagnosis of congenital cytomegalovirus associated with close follow-up.

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DOI: 10.3897/folmed.63.e54559

Authors: Gergana Vazheva, Liliya Zisova

Abstract: Tinea barbae profunda is a rare mycotic infection of the beard, caused by dermatophytic fungi. Patients with suppressed immune systems and severe comorbidities, such as diabetes mellitus, are more prone to this disease, but it could also be seen in agricultural workers and stockbreeders. The most frequent etiological agents of this infection are the zoophilic dermatophytes. But in rare cases, an infection with anthropophilic dermatophytes as Trichophyton rubrum can be observed.We present a case of a 55-year-old patient with insulin-dependent diabetes mellitus and tinea barbae profunda, caused by Trichophyton rubrum, as a consequence of autoinoculation from concomitant Tinea pedis. The patient was treated with oral antibiotics before admission to the clinic, but with no effect due to incorrect diagnosis and lack of mycological laboratory investigations. A satisfactory therapeutic outcome was achieved after a two-month course with antimycotic medications.

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DOI: 10.3897/folmed.63.e52883

Authors: Stephanie Salim, Lokot Donna Lubis, Cut Adeya Adella, Milahayati Daulay, Eka Roina Megawati

Abstract: Introduction: Nowadays, acute respiratory infection (ARI) is the most common cause of high morbidity and mortality rate in children. ARI is defined as an infection either in the upper or lower respiratory tract that lasts for 14 days and caused by either viruses or bacteria. The incidence of ARI in 2017 is 20.54%, with the most prominent characteristic in children aged 1 to 4 years. Factors that affect ARI frequency are gender, birth weight, nutritional status, immunization status, vitamin A status, exclusive breastfeeding, smoke exposure, family income, and mother’s formal education.Aim: This study aims to find out risk factors that potentiate ARI among children from age 1 to 5. Materials and methods: This study used a descriptive-analytical method with a cross-sectional study approach. The data is taken by consecutive sampling method with a questionnaire as the tool. Results: The bivariate analysis result using Fisher’s exact test shows that there is no relation between sex (p=0.642), birth weight (p=0.683), completion of immunization (p=0.195), vitamin A supplementation (p=1.000), exclusive breastfeeding (p=0.157), crowding (p=1.000), family income (p=0.658), knowledge (p=1.000), attitude (p=0.156), and behavior (p=1.000) with the frequency of ARI. The bivariate analysis result using Kruskal-Wallis test shows that there is no significant difference between groups in each factor of smoke exposure (p=0.988) and mother’s formal education (p=0.899) with the frequency of ARI.Conclusions: There is no relation between each factor with ARI frequency and there is no significant difference between groups in each factor with ARI frequency.

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DOI: 10.3897/folmed.63.e53580

Authors: Mohammad Soleimani, Abbas Morovvati, Keyvan Majidzadeh-A

Abstract: Introduction: Detection of Neisseria meningitides by using conventional methods is time consuming and laborious. Development of a realiable and rapid method for prompt control and prevention of meningococcal disease is required. Although PCR and real time PCR methods have been developed; they require electrophoresis or expensive Devices. LAMP is a simple gene amplification method which can be performed at a single temperature without the need for thermal cycling.Objective:We aimed to develop a quantitative real-time LAMP assay for detection of N. meningitides and accurate quantification of the bacterial load in patients with meningococcal disease.Material and Methods: the LAMP reaction was set up and optimized by four primers were designed. Amplification results were assessed by obtained real time turbidity graphs from each LAMP reaction tube using real time turbidimeter apparatus. Standard curve was generated from turbidity graphs corresponding to ten-fold serial dilution of crgA gene containing recombinant plasmid. Results: by LAMP assay just N. meningitides isolated, whereas no amplification was obtained with negative control isolates, and this indicating 100% specificity. The limit of detection (LOD) of our LAMP assay was found to be ~ 5 copies of crgA gene per reaction.  REAL LAMP Analysis of the standard curve revealed excellent linear correlation between gene copy number and time threshold. With a coefficient correlation equal to 0.92.Conclusions: The REAL LAMP assay is a rapid, simple, cost-effective, sensitive, and specific method for detection of N. meningitides, it has the potential for application in epidemiological studies and biodefence situations

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DOI: 10.3897/folmed.63.e53479

Authors: Roohollah Fateh, Ali Javadi, Jalil Kardan-Yamch, Hossein Ali Rahdar, Masumeh Amini, Fatemeh Ghasemi, Akram Azimi, Masoumeh Davarpanah, Razieh Mohammadzadeh

Abstract: Introduction: Helicobacter pylori is considered a major agent causing gastritis and peptic ulcer disease. Unfortunately, the occurrence of increasing drug resistance to this bacterium would result in some difficulties in its treatment. Therefore, the application of nanotechnology has been suggested to resolve such problems. Nanoparticles usage in medical research has been expanded in recent years. Among nanometals, gold nanoparticles have exclusive features that can be used in such applications. Using nanotechnology in medical science could help mankind to solve this problem in the future.Aim: Our aim in this research was to investigate the antimicrobial effect of gold nanoparticles on H. pylori strains.Materials and methods: Gold nanoparticles were synthesized by the Turkevich method. Then, their size and dispersion were investigated using spectrophotometry, DLS, and TEM microscopy. Subsequently, the combination of metronidazole and gold nanoparticles was obtained by mixing method, and then the anti-helicobacter effects of the two were evaluated according to CLSI.Results: The highest size of gold nanoparticles was between 12 and 9 nm, and the maximum absorbance was 522 nm; however, in conjugated state, the maximum absorbance was 540 nm, which indicated the accumulation of drug-conjugated nanoparticles in the conjugate state. Some changes indicated the binding of metronidazole to gold nanoparticles. Antimicrobial testing of gold nanoparticles and metronidazole did not affect the Helicobacter pylori. Therefore, the combination of gold nanoparticles and metronidazole had a 17-mm growth inhibition zone.Conclusions: The anti-helicobacter effects of metronidazole significantly increased in conjugation with gold nanoparticles.

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DOI: 10.3897/folmed.63.e64415

Authors: Georgi Popov, Margarita Gospodinova-Bliznakova, Zlatko Kalvatchev, Andrey Tchorbanov

Abstract: Aim: Prevention and treatment of upper respiratory tract infections are given the highest priority because of the tremendous health and economic impact of these diseases. Development of novel effective and safe options for treatment can contribute considerably to decrease the burden of disease.Materials and methods: We designed a multicenter, randomized, double-blind, placebo-controlled study in ambulatory-treated adult patients with a clinical diagnosis of acute upper respiratory tract viral infection. The patients (18-60 years old) were randomized into two groups and followed-up for 5 days. Group 1 received the standard symptomatic therapy + Aviron Rapid®, and Group 2 received the standard symptomatic therapy + placebo. The primary endpoint of the study was defined as the duration of disease measured by the percentages of disease-free patients for every 12-hour period of the study. Results: Treating clinically relevant patients with the natural product Aviron Rapid® for 5 days decreases the duration of disease, the intake of antipyretics and the severity of symptoms. Significant difference between the tested groups for most of studied parameters was found as soon as 12 or 24 hours after initiation of administration in favour of active arm and was the most prominent on days 3 and 4. Significant decrease in the total score of symptoms severity was achieved on day 4 and extended to the end of study. There were no dif-ferences in the adverse events between the groups and the tested product demonstrated excellent safety profile. Conclusions: This study is a clinical confirmation of well documented antiviral activity of the product targeting multiple points in viral replication and covering broad spectrum viral pathogens.

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DOI: 10.3897/folmed.63.e53506

Authors: Milad Shahini Shams Abadi, Asieh Taji, Fatemeh Salehi, Hossein Kazemian, Hamid Heidari

Abstract: Enterococci have been considered as one of the most common causes of nosocomial infections. The spread of antibiotic resistance has posed a serious challenge to treating the enterococcal infections. High-level aminoglycosides resistance leads to failure in the synergistic combination therapy. This study aimed to estimate the prevalence of high-level gentamicin resistance (HLGR) among clinical isolates of enterococci in Iran.Systematic literature search was conducted in the Web of Science, PubMed, Scopus and Google Scholar electronic databases from ar-ticles which were published from April 2000 to September 2018. Literature search yielded 918 studies. Eligible studies were selected ac-cording to the defined inclusion and exclusion criteria. Statistical heterogeneity was estimated by Q statistic and the I2 index. The Begg’s rank correlation test and Egger’s weighted regression tests were used to evaluate possible publication bias.Nineteen studies were included in this review. According to the meta-analysis results, the prevalence of HLGR among Enterococcus spp. was 49.4% (95% CI: 42.2%-56.6%). It was estimated 44.3% (95% CI: 38.1%-50.8%) and 66.3% (95% CI: 51.4%-78.6%) for E. faecalis and E. faecium, respectively.Since notable rate of HLGR in enterococci was seen in this analysis, improving the implementation of all aspects of the infection control programmes is required. Accurate and regular monitoring of infection control procedures are necessary for reducing the dissemination of such infections.

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DOI: 10.3897/folmed.62.e50486

Authors: Spasimir T. Shopov

Abstract: Perianal and perineal pruritus is often associated with Enterobius vermicularis in children. Although this roundworm is common in pediatric practice, most doctors are unaware that it can cause appendicular colic with/or appendicitis, severe urogenital complications, bowel perforation, and peritonitis. We report a case of a young male who presented with signs and symptoms of acute peritonitis. Dur-ing the operation, perforation of the jejunum with a purulent exudate under the transverse colon, a left lateral canal, a Douglas cavity were found as well as single enlarged mesenteric lymph nodes. Histological studies detected Enterobius vermicularis in the lumen of the appendix and jejunum, as well as in the purulent exudate in the intestinal wall and serosa. A mesenteric lymph node, histologically presented with chronic nonspecific lymphadenitis. In conclusion, infection with Enterobius vermicularis should be considered in peri-tonitis, appendicitis, and enlarged mesenteric lymph nodes, especially in young patients.

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DOI: 10.3897/folmed.62.e51225

Authors: Stanislav Kotsev, Iva Christova, Maria Pishmisheva-Peleva

Abstract: West Nile fever (WNF) is a vector-borne infection caused by a Flavivirus-West Nile virus (WNV). WNV is transmitted by mosquitoes, and birds are the major natural reservoir. A recent increase in the number of the WNF cases has been reported in Europe, the Balkans, and Bulgaria. We herein present the clinical course, laboratory and imaging findings of three patients – a female and two male patients, who were diagnosed with WNF. They were investigated in an epidemiological study, and by using clinical observation, laboratory and microbiological methods, serological tests for specific anti-WNV antibodies detection, molecular biology techniques (polymerase chain reaction, PCR), computed tomography (CT) and magnetic resonance imaging (MRI). The patients presented with fever, headache, drowsiness, and dizziness and anti-WNV antibodies were detected in their serum samples. WNV-RNA was found in a blood sample from the female patient. Both anti-WNV IgM and Herpes simplex virus-1 DNA were detected in a cerebrospinal fluid sample from one of the men. The three patients recovered from the disease after a long convalescent period. WNF has no specific signs, laboratory and imaging findings and could be a life-threatening condition, leading to serious complications. Therefore, WNF should be taken into consideration during the summer when the vector of the infection is active.

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DOI: 10.3897/folmed.62.e50437

Authors: Vanya Rangelova, Ralitsa Raycheva, Ani Kevorkyan, Maya Krasteva, Tihomir Dermendzhiev

Abstract: Introduction: Nosocomial infections (NI) are frequent complications in neonatal intensive care units (NICU) which result in high morbidity and mortality.Aim: To determine and analyze the incidence, risk factors and etiologic agents of NI in newborns admitted in the NICU to help plan-ning future surveillance and prevention strategies.Materials and methods: A prospective cohort study was carried out at the NICU of St George University Hospital, Plovdiv, Bul-garia from January 1, 2017 to June 31, 2018. The number of neonates included in the study was 507. Descriptive statistics such as count, percent, mean and standard deviation was used. Chi-square test was performed to prove associations. Odds ratios, with 95% confidence intervals, were computed from the results of the binominal logistic regression analyses.Results: Of the 507 hospitalized newborns in NICU, 48 presented with 54 NI. The incidence and the density incidence rates were 9.5% and 7.67 per 1,000 patient-days, respectively. Nosocomial infections were detected in neonates from all birth weight (BW) classes, but it was low BW and premature neonates that were at major risk to acquire them. The most common infection sites were ventilator-asso-ciated pneumonia (VAP) (67.27%), bloodstream infection (23.64%) and conjunctivitis (9.09%). Major pathogens were Gram-negative such as Klebsiella pneumoniae, E. coli, Pseudomonas aeruginosa and Acinetobacter baumannii. In the multivariate logistic regression analysis NIs were strongly associated with intubation, presence of a venous catheter, the duration of antibiotic treatment and increased CRP> 10 mg/l.Conclusions: This report highlights the burden of NIs, identifies the major focus for future NI control and prevention programs.

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DOI: 10.3897/folmed.62.e49812

Authors: Ralitsa Raycheva, Yordanka Stoilova, Ani Kevorkyan, Vanya Rangelova

Abstract: Introduction: Epidemiological forecasting facilitates scientifically sound solutions to upcoming theoretical and practical issues, in the development of public health management, in particular of infectious diseases.Aim: To critically analyze the most recent scientific advances in the biosocial nature and methodology of epidemiological forecasting to present a real-life example of pertussis, a disease with shifting epidemiology.Materials and methods: For the prediction of pertussis morbidity the autoregressive integrated moving average (ARIMA) the model was established by utilizing the method of time series analysis to construct a model of overall morbidity using Time series modeller in SPSS v.25. To model pertussis morbidity we obtained official data from the Ministry of Health and the National Center for Infectious and Parasitic Diseases, since the beginning of disease registration from 1903 until 2018. We also analyzed the shifting epidemiology of pertussis.Results: The proper identification procedures we applied indicated ARIMA (3,0,0) model to best fit our original time series of the annual whooping cough morbidity for the 1921-2018 period. The model predicts better morbidity in a one-step forecast. The incidence rate is expected to be stable at about 1.35 per 100,000 in the next three years, which is close to the 2016 level and lower than those in 2017-2018.Conclusion: The ARIMA (3,0,0) model in our study is an adequate tool for presenting the pertussis morbidity trend and is suitable to forecast near-future disease dynamics, with acceptable error tolerance.

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DOI: 10.3897/folmed.62.e48742

Authors: Dionysia D. Fermeli, Theodoros D. Marantos, Alexandros-Leonidas D. Liarakos, George D. Panayiotakopoulos, Vasileios K. Dedes, Georgios I. Panoutsopoulos

Abstract: Tuberculosis is a severe, infectious disease caused by Mycobacterium tuberculosis. The aim of this review was to present the efficacy of linezolid as an agent against multidrug and extensively drug-resistant tuberculosis as gathered from many recent research studies. Linezolid seems to have strongly the potential of being used as an anti-tuberculosis agent because it blocks bacterial ribosomal protein synthesis. Nevertheless caution is required because of the adverse effects it causes, especially when the linezolid daily dosage exceeds 600 mg. The most severe adverse effects include anemia, peripheral neuropathy, optic neuropathy and thrombocytopenia. Still, more trials and research need to be done in order to gather more information and value the cost-benefit dosage of the treatment.

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DOI: 10.3897/folmed.62.e49840

Authors: Zhivka Stoykova, Liliya Ivanova, Snejinka Cvetkova, Diana Yordanova

Abstract: Background: Cytomegalovirus (CMV) is a worldwide spread herpes virus that establishes a latent infection after the primary infection. It becomes a major problem in immunocompromised patients and in cases of primary or reactivated infection during pregnancy. CMV is the most common congenital infection and is the leading infectious cause of sensoneural deafness and cerebral mental retardation.Aim: Тo raise the attention to the discordance in our knowledge of cCMV infection and the implementation of the knowledge in prac­tice.Materials and methods: CMV-DNA was extracted from saliva and plasma samples according to the protocol of DNA-Sorb-A, Sacace, Biotechnologies, Italy. Polymerase chain reaction (PCR) was performed using a commercial kit based on the Taq-man principle: Quantitative RT-PCR for CMV-DNA detection (Sacace, Biotechnologies, Italy). The linear range of the CMV Real-TM Quant PCR test is 500-10000000 copies/ml, and the reported sensitivity is 400 copies/ml.Results: The infant was born with clinical manifestations involving development of hepatosplenomegaly, chorioretinitis, anemia, mi­crocephaly and simultaneous dilatation of the brain ventricles. CMV infection was confirmed using modern PCR studies.Conclusions: This case highlights the need for specific virological/PCR tests to be performed for all children with the least suspected congenital infection, especially when there is an option of a specific treatment.

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DOI: 10.3897/folmed.62.e47220

Authors: Elizabeta Bachiyska, Yuliana Atanasova, Ana Baykova, Stanislava Yordanova, Yana Todorova

Abstract: This study aimed to describe the first two microbiologically confirmed cases of cutaneous and soft tissue Mycobacterium marinum infection in Bulgaria. The isolation of the Nontuberculous Mycobacteria (NTM) strains and their species identification was performed at NRL TB, NCIPD using specific media and cultivation conditions, and PCR based Line Probe Assay (LPA) from the positive cultures. The two patients had closely related jobs to fishes and water reservoirs and both of them had a similar clinical manifestation of M. mari­num infection known as “swimming pool” or “fish tank” granuloma. The prolonged specific treatment with at least two-drug combina­tion of rifampicin plus ethambutol and some complications were a big challenge for clinicians as well as the patients.

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DOI: 10.3897/folmed.62.e39599

Authors: Teodora Karteva, Neshka Manchorova-Veleva

Abstract: The immune response is a complex, dynamic and strongly individual biologic network that plays an essential role in the pathogenesis of chronic apical and marginal periodontitis. Recent research in the field of periodontology has indicated that the major determinant of susceptibility to disease is the nature of the immunoinflammatory response as marginal periodontal tissue damage is thought to be primarily mediated by the host reaction. Whether the same rules apply for the development of apical periodontitis, however, remains largely unexplored. This review aims to draw parallels between the pathogenesis of chronic periodontitis of endodontic and marginal origin, outline the evidence for the destructive role of immune response in chronic marginal periodontitis and raise questions about its role in chronic apical periodontitis. It would be worthy to further explore the impact of the immune system on the characteristics and progress of these diseases and transfer some of the scientific models from the field of periodontology to the field of endodontics. Research in this area could lead to a more comprehensive understanding of the dynamics of apical and marginal periodontitis and lay the foundation of new personalized treatment strategies.

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DOI: 10.3897/folmed.61.e47811

Authors: Yordan I. Kalchev, Gergana B. Lengerova, Uswah Asif, Hasan A. Burnusuzov, Marianna A. Murdjeva

Abstract: Multimodal therapy, used for the treatment of patients with Hodgkin’s disease (HD), makes them prone to life-threatening infections, attributed mainly to febrile neutropenia. Herein, we present a case report of fatal combined bacterial and viral infection in a 49-year-old female patient, subject to polychemotherapy for HD. Rapid microbiological diagnosis performed by multiplex polymerase chain reaction elucidated the causes of the infection within hours. Listeria monocytogenes was detected in both the cerebrospinal fluid and blood samples. Nasopharyngeal swabs returned positive for two swine-derived strains of influenza A virus. We aimed to emphasize the importance of these pathogens and draw attention to their association in the aetiology of infections among patients receiving chemotherapy. In conclusion, better surveillance is needed to improve the early diagnosis of infectious complications in these patients.

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DOI: 10.3897/folmed.61.e47949

Authors: Galina Gavazova, Eli Hristozova, Stanimir Kisselov, Ralitsa Raycheva, Petia Pechalova

Abstract: Aim: To observe bacteremia following closed and open dental extraction.Material and methods: The study included two subject groups each comprising 29 participants. Group I patients received a single closed dental extraction, and group II patients – a single open extraction. Venous blood from the cubital vein of each patient was collected in three samples – preoperatively, 30 seconds after surgery, and 15 minutes after surgery. Anaerobic and aerobic hemocultures (Bact/ALERT, BioMerieux, Inc., Durhamn, N.C.) were used to study the bacteremia process.Results: Preoperatively, bacteremia was confirmed in 4 patients (6.9%) undergoing closed extraction and in 1 patient (1.7%) undergoing open extraction. Additionally, we found statistically significant relation between bacteremia and age (p=0.002). Thirty seconds after surgery bacteriemia was evident in 6 patients (10.3%) from group I and in 3 (5.2%) from group II. Fifteen minutes following surgery bacteremia was evident in 4 patients (6.9%) undergoing typical extraction and in one patient (1.7%) undergoing surgical extraction. No statistically significant relation between type of extraction and presence of bacteria in the bloodstream at 30 seconds (p=0.285) and at 15 minutes (p=0.166) was found. Coagulase-negative Staphylococcus was the most frequently found microorganism (22.2% of aerobic and 11.1% of anaerobic hemocultures). The results show greater significance of bacteremia at 30 seconds, compared to preoperative samples for both subject groups (p=0.03).Conclusions: Bacteremia following dental extraction is unaffected by duration of intervention, type of extraction and gender.

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DOI: 10.3897/folmed.61.e47760

Authors: Denitsa T. Tsaneva-Damyanova, Liliya I. Ivanova, Silviya N. Pavlova, Svetlana B. Todorova, Tsvetelina K. Popova

Abstract: Introduction: Hepatitis B virus (HBV) is one of the most significant human pathogens responsible for a huge number of acute and chronic liver infectious diseases worldwide.Aim: To find the duration of post-vaccination immune response in individuals allocated to five age groups from 6 months to 20 years.Materials and methods: All tested subjects were born between 1999 and 2018 and therefore covered by the compulsory vaccination program against hepatitis B. For the serological marker anti-HBs Ab we investigated 449 serum samples taken from ambulatory people and patients of St Marina University Hospital in Varna.Results: A positive antibody response (anti-HBs Ab > 10 mIU/ml) was reported in 79.7% (n = 51) of the group of subjects up to one year old, in 70.0% (n = 196) of the subjects in the age range 1 year/1 month to 15 years, and in 39.3% (n = 33) of the subjects 15 years/1 month to 20 years old. Female sex had a better post-vaccination response than male sex with statistically significant relationship between sex and anti-HBs Ab titer (χ2 = 24.76, p <0.01).Conclusions: Regardless of the mass immunization against HBV in Bulgaria, the relative share of chronic HBV infections does not show a downward trend. Therefore, it is very important to study the duration of the post-vaccination immune response by demonstrating the anti-HBs antibodies and to apply a booster dose from the vaccine if needed.

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DOI: 10.3897/folmed.61.e47941

Authors: Raina T. Gergova, Virna-Maria S. Tsitou, Ivan G. Mitov

Abstract: Background: Invasive infections caused by methicillin resistant Staphylococcus aureus and coagulase-negative staphylococci (MRSA/MRSCoN) require fast, adequate treatment. The aim of this study was to develop a faster protocol for direct detection of MRSA/MRSCoN in blood cultures and in abscess punctures based on mecA and species specific identification of S. aureus by polymerase-chain reaction (PCR).Materials and methods: We examined 77 growth-positive BACTEC blood cultures and 50 abscess punctures by routine microbiological assay and simultaneous PCR detection of MRSA/MRSCoN. The specificity of the PCR was evaluated by using DNA from another 15 microbial species for negative controls. We determined the minimum inhibitory concentration (MIC) of oxacillin, vancomycin, tigecycline, linezolid, levofloxacin, clindamycin, and erythromycin against the S. aureus isolates using the E-test. Results: In the blood cultures, the two methods detected 39.3% of MRSA, and 93.9% of MRCoNS. In the punctures, the PCR assay identified 20.9% of MRSA and 79.2% of MSSA. In the puncture cases, there were three PCR MRSA positive and culture negative samples. Screening for susceptibility to 14 antimicrobial agents demonstrated significantly higher (p<0.05) methicillin resistance in blood culture isolates than in the puncture ones (39.3% and 20.0%, respectively). Conclusion: The new PCR protocol was very fast and specific. It was more sensitive in detecting MRSA from abscess punctures than the routine microbiological techniques. This protocol will speed up the right choice of empirical therapy, which is extremely important for saving patients’ lives.

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DOI: 10.3897/folmed.61.e39349

Authors: Dobromira I. Dimitrova, Rumyana D. Markovska, Temenuga J. Stoeva, Petya B. Stankova, Lyudmila B. Georgieva, Kalina I. Mihova, Radka P. Kaneva, Ivan G. Mitov

Abstract: The aim of the present study was to reveal the characteristics of an Enterobacter cloacae complex isolate producing DHA-1 AmpC enzyme recovered from a patient hospitalized in St Marina Hospital, Varna.Materials and methods: Susceptibility testing, conjugation experiments, isoelectric focusing, PCR and sequencing were carrying out.Results: Of 176 Enterobacter spp. isolates only one isolate was positive for blaDHA. The sequencing revealed the presence of blaDHA-1 and blaCTX-M-3. The antimicrobial susceptibility testing showed higher resistance rates to almost all beta-lactams (ceftazidime, cefotaxime, cefepime, amoxicillinclavulanic acid, piperacillin/tazobactam), tobramycin, gentamycin, trimethoprim/sulphomethoxazole and quinolones (ciprofloxacin and levofloxacin). The isolate was susceptible to imipenem, meropenem and amikacin. The isoelectric focusing showed a band at pI 5.4 without ceftazidime and cefotaxime activity; a band at pI 7.8 with cefoxitin activity and another - with pI 8.4 with cefotaxime activity. Conjugation experiments were successful only for blaCTX-M-3 carrying determinants. Conclusions: To the best of our knowledge this is the first report of DHA-1 producing isolate in Bulgaria. The emergence of DHA-1 producing E. cloacae complex demonstrates the possibility for further dissemination of the gene encoding this enzyme. Infectious control measures are needed for the prevention of this phenomenon.

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