Meningitis, Fungal

Entrance of Exotic Pathogens into the Brain

CNS infections are life-threatening diseases caused by viral, bacterial, parasitic, and fungal microorganisms, including meningitis, encephalitis, and brain abscess. These infections are linked to significant illnesses and death rates. CNS is characterized by a specific structure and function. Despite a unique system of brain barriers and an autonomous immune system, CNS is very susceptible to microorganisms, which may invade directly via the BBB, blood, or less frequently by reverse axonal transport.

Promising Nano-Carriers-Based Targeted Drug Delivery Approaches for the Effective Treatment of Alzheimer’s Disease

Alzheimer’s disease (AD) is an attained disorder of cognitive and behavioral impingement with progressive symptoms over time. It is mostly witnessed in elderly people, and as per the World Health Organization (WHO), it has affected more than 35 million people worldwide, and this figure is presumed to double by the year 2050. The most commonly believed cause of AD is the accumulation of beta-amyloid, which forms extracellular plaques. Presently conventional therapy for treating cognitive impairments in AD relies on a neurotransmitter or enzyme modulation strategy. Conventional approved drugs, such as acetylcholinesterase inhibitors (memantine, tacrine), are widely available for the treatment of mild to moderate AD, but due to their lower bioavailability, poor solubility, and ineffective capability to surpass the blood brain barrier (BBB), they often fail to produce the desired effect. The potency of conventional AD drugs is highly dependent on various physiological aspects such as BBB; blood-cerebrospinal fluid barrier and drug efflux by P-glycoprotein, which all hampers the capabilities of AD drugs to grasp the central nervous system (CNS). So, in order to conquer the hurdle and these existing limitations faced by CNS drugs to cross the BBB, innovative pathways in drug development have become the need of the hour. Various nanocarriers based approaches profitably meet this demand by improving the efficacy as well as facilitating the sustained release of the entrapped AD drug via targeted drug delivery. The blood-brain barrier offers protection to the central nervous system and also limits the entry of therapeutic molecules to the CNS. On the other hand, nanotechnology offers the possibility to deliver small molecules against CNS disorders across BBB due to their enormous properties, such as small surface area, controllable physicochemical properties, higher drug payload, and better drug circulation time. Plenty of nanocarriers and nanoparticle prodrugs have been reported to have inconsequential cytotoxicity in preclinical studies, and these advancements have proclaimed a new juncture for the development of new classes of nano carriers’ based potent drug formulations for the treatment of AD. A plethora of nanotechnology-based approaches such as polymers, emulsions, lipo-carriers, solid lipid carriers, carbon nanotubes, and metal-based carriers have been redefined over time, and they have been successfully focusing on both neuroprotective and neurogenerative techniques for treating AD. Many researchers also reported that nanotechnological-based techniques can improve the early diagnosis of AD and enhance the therapeutic efficacy and bioavailability of drugs.

Marine Natural Products as Tools for Discovering New Antimicrobial Targets

The discovery of drugs for human ailments has been greatly attributed to nature ever since the existence of mankind. Continuous isolation of metabolites from terrestrial resources leads to a bargaining effect on the synthesis of novel compounds. Remarkably, marine biotope, one of nature’s resources, accommodates approximately 75% of the global surface. To acclimatize in a marine environment characterized by unique circumstances that diverge from the individuals present in other habitation, marine organisms occasionally accumulate structurally distinctive bioactive secondary metabolites that are deficient in terrestrial organisms. Marine metabolites are currently employed as the key components in pharmacological research and drug discovery, acting as drugs and active lead molecules towards the development of novel antimicrobials. Numerous marine metabolites that are derived from macro and microorganisms have attained the level of clinical assessment. Hence, marine environments are considered tools for discovering new antimicrobial agents as they comprise a vast untapped reservoir of metabolite diversity.

Antibody Therapy as Alternative to Antibiotics

In the 1890s, Behring and Kitasato established the principle of serum therapy, which proved useful in treating infectious diseases. However, by the 1940s, serum therapy was abandoned mainly due to complications associated with the toxicity of heterologous sera and the introduction of more effective antibiotics. Although the availability of antibiotics had a tremendous impact on saving lives from infectious diseases, there was a rapid emergence of antibiotic resistance. As a result, an alternative therapy is being given due consideration. With the advent of antibody production technology, antibody therapy has gained interest as a promising treatment for emerging infectious diseases. Some monoclonal antibodies (mAbs) had already been approved for the treatment of certain infectious diseases. Many mAb candidates are currently in different phases of clinical testing for a variety of infectious pathogens. There is hope that antibody therapy may appear as a promising treatment option against infectious diseases in the near future.

Natural Sources of Immunomodulators

Nature is replete with an arsenal of compounds that can be investigated for their therapeutic potential. The immune system involvement in severe chronic illnesses or emerging infectious diseases has provided clinical evidence. The prevention and treatment of these diseases targeted at the immune system with natural immunomodulators are gaining momentum, owing to their diverse array of activities. Treating acute illnesses with modern medicines has been successful; however, treating chronic illness treatment remains elusive and disappointing. Notably, this chapter reviews the natural resources of immunomodulators. Natural immunomodulators from plants, marine, and animals are of prime importance, and they possess many pharmacological activities. Similarly, microbiota modifiers - prebiotics, probiotics, and micronutrients- are imperative in restoring immune homeostasis. This chapter summarizes these natural immunomodulators and their power to boost immunity and human well-being.

Subject Index

Current Antifungal Drugs

Fungal infections are one of the major causes of fatalities worldwide, causing an estimated 1.5 million deaths annually. Over the past few decades, the incidences of fungal infection have risen with the increase in the cases of immunocompromised patients. However, the impact of fungal diseases on public health is often underestimated. These infections are predominantly caused by the Aspergillus, Candida, and Cryptococcus species. Current therapeutic approaches to treat such fungal infections are limited to five distinct classes of antifungal drugs, viz. polyenes, echinocandins, azoles, pyrimidine analogs, and allylamines. Moreover, a few synthetic molecules are also used as fungicidal agents. Despite the current antifungal armamentarium, the burden of fungal infection is exacerbated by the emergence of drug resistance, host toxicity, and negative interactions with other drugs. The paucity of new antifungal drugs has further complicated the treatment of fungal infections. These limitations provide a rationale for developing novel antifungals preferably with new mechanisms and molecular targets. This chapter thus summarizes the currently used antifungal drugs, their effective combinations, and the challenges inherent to the development of new antifungal drugs. The chapter also addresses strategies to bolster the antifungal pipeline involving emerging new targets for better management of fungal infections.

Emergence of Multidrug Resistance Microbes: Bacteria, Fungi, and Viruses

Increased incidences of multidrug-resistant (MDR) microorganisms has become a global health concern for humans, animals, and agriculture. The advent of newer resistance mechanisms evolving in microorganisms at a high rate compared to the treatments available urges the need to understand its origin and reservoirs. The expanded use of antimicrobial drugs, inefficient diagnosis as well as broad use in agriculture and veterinary contributes to the emergence of resistance in microorganisms. Presently, almost all infectious agents (bacteria, fungi, and viruses) have developed MDR. About 7 lac people die of bacterial resistance to antibiotics every year, with an estimated ~10 million deaths by 2050. Similarly, MDR arising in pathogenic fungi like Candida, Aspergillus, or Fusarium to the limited therapeutic options is highly challenging. Bacteria and fungi develop resistance mainly due to biofilm formation, increased efflux pump activity, drug target mutations, drug binding alterations, chromosome abnormalities, and the ability to escape host immune defenses. The co-existence of MDR bacteria and fungi forming biofilms is even much of an alarm in medicinal applications. Apart from these, drug resistance to current antiviral therapeutics has imposed significant risk amidst life-threatening diseases caused due to viruses like HIV and influenza A. Owing to its severity and complexity, we aim to illustrate the detailed mechanism and evolution of MDR in bacteria, fungi, and viruses. We also review different approaches to deal with MDR, emphasizing alternatives, vaccine development, global surveillance programs and stewardship measures to combat resistance.

Subject Index

Biomarkers and their Clinical Applications in Pediatrics

Biomarker studies are becoming increasingly interesting for many fields of medicine. The use of biomarkers in medicine is involved in detecting diseases and supporting diagnosis and treatment decisions. New research and new discoveries on the molecular basis of the disease show that there may be a number of promising new biomarkers for use in daily clinical practice. Clinical trials in children lag behind adult research both in quality and quantity. The number of biomarkers validated to optimize pediatric patient management is limited. In the pathogenesis of many diseases, it should not be extrapolated to the pediatric clinical setting, taking into account that biomarkers that are effective in adults are clearly different in children and that ontogeny directly affects disease development and therapeutic response in children. The search for ideal biomarkers or markers that can make an early and definitive diagnosis in neonatal sepsis is still ongoing. The ideal biomarker for pediatric diseases should be costeffective, noninvasive, applicable to pediatric specific diseases, and its results should correspond to age-related physiological changes. Lactate, troponin and B-type natriuretic peptide are valuable biomarkers in the evaluation and management of critically ill children with cardiac disease. Tumor markers in children are biochemical substances used in the clinical treatment of pediatric tumors and to detect the presence of cancer (regression or progression). In this chapter, current and brief information about biomarkers and their clinical applications used in the diagnosis and monitoring of pediatric diseases is presented.

Early Detection of Crop Fungal Pathogens for Disease Management using DNA and Nanotechnology Based Diagnostics

Virulent fungal plant pathogens are a serious threat to crop productivity and are considered a major limitation to food security worldwide. To meet these challenges, pathogen detection is crucial for taking appropriate measures to curb yield losses. Disease diagnosis at an early stage is one of the best strategies for crop protection. Earlier, traditional methods were used to diagnose and manage fungal diseases, which included visual scouting of the disease symptoms and spray of fungicides. The utility of immunoassays for early detection and precise identity has been appreciably stepped forward following the improvement of enzyme-connected immunosorbent assay (ELISA) and monoclonal antibodies. Nucleic acid-based diagnostic techniques have turnout to be the preferred type because of their greater speed, specificity, sensitivity, reliability, and reproducibility. The biosensor eliminates the need of sample preparation and can be used for on-site detection of fungal pathogens at latent infection stages so that preventive measures can be taken. Currently, multiple human and animal diseases have been detected with the help of biosensors. However, reports on plant pathogen detection using biosensors are still in infancy. Despite many applications of antibodies, there are also multiple drawbacks, including high cost, low physical and chemical stability, and the ethical issues associated with their use. Now, DNA based biosensors are gaining popularity because of their sensitive and precise detection of DNA target sequences. Immunological and DNA-based techniques combined with nanotechnology offer highly sensitive and selective gel-free detection methods, and the lab-on-chip (LOC) feature of biosensors makes them a very reliable tool in crop protection.

Antimalarial, Antibiotics, Antibacterial and Antifungal Drugs

This chapter deals with the class of aminoquinolines or quinolone

antimalarial, antibiotic, antibacterial and antifungal drugs. Brand names of the

antimalarial agent (e.g. Chloroquin, Primaquine), antifungal agent (e.g. Fluconazole),

antibiotic agent (Nalidixic acid, Norfloxacin, Chloramphenicol), antibacterial and

antifungal agents (Sulphonamides, Sulfamethoxazole, Sulphacetamide, Trimethoprim)

along with the uses, mode of action and side effects have been discussed in this

chapter. Various synthetic methods have shown for these drug molecules. Different

types of name reactions have included as the key for their synthesis.

Introduction of Common Pediatric Diseases

Pediatric health has improved over the past decades and there is a decline in deaths caused by infectious diseases. Yet, the top three causes of disease in children younger than 10 years in 2019 include neonatal disorders, lower respiratory tract infections, and diarrheal diseases. While in the adolescence age group, the major causes are road injuries, headache disorders, and self-harm. Preterm birth complications, pneumonia, and birth asphyxia are the most leading cause of death in children under five years. While in the five to nine years of age group, injuries, including road traffic injuries, drowning, burns, and falls, are the leading causes of death.

Subject Index

Immunotherapy of Sepsis

Sepsis is a clinical condition that occurs due to dysregulated fundamental

host reaction to an infection, resulting in organ dysfunction. Proinflammatory

mediators are related to indications watched early in patients with sepsis. In spite of

decades of investigation, the morbidity and mortality of sepsis stay exceptionally very

high. Regardless of the recognition of numerous prospective targets in the complex

immune response pathways, no specific immunotherapeutic medicines are at present

accessible. Presently, immunosuppression in sepsis is a subject matter of strong

research amongst various pre-clinical and clinical studies. In fact, an improved

consideration of a patient’s immune status on a constant basis will plausibly allow

focused immunotherapy. This book chapter provides an overview of the epidemiology,

etiology, pathogenesis of sepsis and gives an outline of the challenges in

immunotherapy for patients suffering from sepsis.

Subject Index

Neurosurgery

This chapter will provide a broad overview of the more common pediatric neurosurgical conditions seen in a children’s hospital setting, with the exception of trauma. Emphasis will be placed on conditions in which the pediatric surgeon and neurosurgeon interface in the care of the child. Also, tips on what to do when a neurosurgeon is not available will be discussed. Extra effort will be spent explaining the various devices pediatric neurosurgeons implant that can very well complicate anticipated or unanticipated general surgical procedures.

Pharmacotherapy of Multiple Sclerosis and Treatment Strategies

Multiple sclerosis (MS) is a well-known chronic inflammatory and neurodegenerative disease of the central nervous system (CNS). It is considered the most common autoimmune demyelinating disease of the CNS. It affects mainly young adult females between 20-40 years of age. MS was previously considered a Tlymphocyte- disease, but now B lymphocytes appeared to have a critical role in MS's pathogenesis. Affected patients showed lower quality of life with an increased death rate than the general population. The treatment of MS is challenging, and many drugs have evolved primarily for the last 20-30 years. Since the introduction of interferons in 1993, there are more than sixteen disease-modifying therapies (DMTs) approved. These drugs have different pharmacologic forms like injections, oral forms, and intravenous infusion drugs. Each one has its benefits and drawbacks. Moreover, like any other patient, MS patient has other symptoms that are not covered by DMT and need symptomatic treatment. In this chapter, we attempt to present medications used to treat acute relapse, different DMTs, symptomatic treatment for different MS symptoms. Besides, we give attention to drugs under clinical trials.

Various Body Fluids

Learning objectives:

1. Describe Cerebrospinal fluid.

2. Discuss Synovial fluid.

3. Explain different exudates in body.

Azadirachta Indica (Neem) in Various Infectious Diseases

The 21st century is witnessing a war between mankind and microorganisms. The worldwide outbreak of infectious diseases is responsible for morbidity and mortality. The pharmaceutical industry has limited drugs in the pipeline against infectious diseases. Resistance of microorganisms against already available drugs is another concern. An initiative from researchers to search for new ways to prevent or treat infectious diseases is necessary. Many herbal drugs are known to be effective against pathogenic organisms from ancient times. Repurposing of herbal medicines for infectious diseases is a prodigious initiative. Azadirachta indica, commonly known as neem, is known to be effective against infectious diseases from ancient times. It is a member of the Meliaceae family. Leaves, seeds, fruits, and roots of this plant are reported to be effective according to Chinese, Ayurvedic, and Unani medicine. The plant has antiviral, antibacterial, and antifungal properties. The principal component of neem is azadirachtin. Other constituents, namely nimbolinin, nimbin, nimbidin, nimbidol, are also known to be having medicinal properties. Antibacterial and antifungal properties can be attributed to azadirachtin, quercetin, ß-sitosterol, gedunin, and polyphenolic flavonoids. Many pharmacological studies report antimicrobial efficacy of Azadirachta indica. The present chapter will explain the link between phytochemical constituents of neem to antimicrobial activity along with possible underlying mechanisms and pathways. Clinical studies on neem are also discussed in great detail to highlight the emergence of this traditional medicine into modern medicine in the battle against infectious diseases.

Obstacles and Challenges in the Use of Probiotics

Probiotics are helpful microorganisms that are resistant to biliary, gastric, and pancreatic secretions and can attach to the epithelial cells and colonize the surface of the intestinal cells. These capabilities are the main mechanisms of probiotics that allow them the adaptation to gut conditions. Probiotic cells attach to the intestinal cells and inhibit the attachment of enteric pathogenic germs to the intestinal mucosa by producing growth-inhibitory elements such as short-chain fatty acids, bacteriocin, and toxic oxygen metabolites. Attaching to the mucosal layer is essential for their functions, but it can increase the possibility of translocation and pathogenicity. On the other hand, there are also concerns about the possible transmission of antimicrobial resistance properties from probiotic strains to pathogenic bacteria in the gut environment. Consequently, the use of probiotics is entirely safe only in healthy people, and also it should be used with caution in children, the elderly, pregnant women, and immunocompromised patients. In recent years, scientists take a new approach to using probiotics in a non-viable form (currently known as postbiotics) to overcome the technological, economic, and clinical problems regarding the application of live probiotics. Hence, this chapter provides an overview of the nutritional and clinical concerns caused by probiotic intake in vulnerable patients, with emphasis on the application of a non-viable form of probiotics as a promising alternative.

Diabetes and Ocular Infections

This chapter will review some of the infections that can be seen in and around the eye in diabetic patients. Specifically, six cases of infection will be highlighted and discussed.

Subject Index

Imaging in Tuberculosis

Tuberculosis is an excellent simulator and can mimic virtually any disease. Clinically, it has been divided into primary and post-primary tuberculosis. Primary tuberculosis usually refers to patients not previously exposed to M. tuberculosis. Primary tuberculosis is more frequent in children, with its highest prevalence in children under five years, although the frequency of primary forms in adults is increasing. The primary disease has four main presentations at imaging: chest lymphadenopathy, pneumonia, miliary disease, and pleural effusion. Post-primary TB (also known as reactivation or secondary TB) most commonly involves the lungs in the apical and posterior segments of the upper lobes and the apical segment of the lower lobes. Initially, there are parenchymal consolidations, that if they are not diagnosed and treated, usually progress to necrosis and cavitation. Unilateral lung destruction is a serious complication of pulmonary TB that occurs in chronic advanced cases. Although TB is mostly limited to the lungs, it can happen in any other tissue or organ, especially in the immunocompromised host.

Subject Index

Antimicrobial Agents

Antimicrobial agents have been the target of numerous research studies for a long period of history and they still attract great research interest namely in what regards to the discovery of newer molecules or the search for newer sources of natural antimicrobials. Antimicrobial agents include drugs, supplements, and ointments which particularly act on bacteria, fungi, comprising molds and yeasts, viruses as well as parasites. Phytochemicals, essential oils, antimicrobial peptides, metal oxides like silver and gold, namely those found as nanoparticles, are being used to treat microbial infections. Antimicrobial pesticides, some of which are isolated from the bacteria themselves, are being studied to help eradicate pathogens in the clinic as well as being used by agricultural companies. There are also various food derivatives that are used as antimicrobial agents. In this chapter, antibacterial, antifungal, antiviral, and antiparasitic antimicrobial agents, which include natural and synthesized molecules used as food additives, are addressed. An outlook of recent advances in drugs and other procedures of treating microbial infections is also given. This chapter also focuses on antimicrobial essential oils and antimicrobial pesticides with a closer look at the effects of heat and radiation as antimicrobial therapies.

Subject Index

Therapeutic Drugs Used for Effective Lifelong Control of HIV and AIDS

AIDS (Acquired immune deficiency syndrome) is caused by the retrovirus HIV (Human immune deficiency virus). HIV destroys T-cells which provide cellmediated immunity (CMI) to human beings. Like other viruses, HIV has a protein capsid and a core RNA genome. HIV infection causes severe damage to the immune system making it vulnerable to various infectious pathogens when the damaged immune system fails to fight the infection, resulting in the advanced stage called AIDS. Two types of HIV exist. HIV-1 is the causative organism of HIV infection worldwide with around 90% of infection. HIV-2 has been reported in a small group of people in western Africa. Both HIV-1 and HIV-2 lead to AIDS in their advance stages. The treatment of HIV infection and AIDS is a big challenge to medical sciences. Many drugs are available that can be used against HIV infection and AIDS. These drugs are known as antiretrovirals (ARVs). ARVs prevent replication of HIV inside the host cell gradually slowing down the progress of HIV infection. Therefore, antiretroviral drugs can prevent AIDS-related complicated diseases and prolong longevity. However, it does not fully restore health. The potential effect of HIV on our health is clearly exhibited by many immunologic abnormalities that occur despite effective suppression of HIV replication by ARVs. The cure for AIDS is still a distant future.

Drugs for Superbugs: Strategies and Methods to Discover New Antibiotics against Drug Resistant Pathogens

The emergence of drug resistance in many bacterial pathogens and the rise of fungal infections have caused a resurgence of interest in finding new reserves of bioactive compounds. The increase in resistance to conventional antibiotics by many bacterial pathogens may be due to the decline in the discovery and development of novel antibiotics. Superbugs are those microorganisms (pathogens) that are resistant to the commonly used antibiotics. The World Health Organisation (WHO) has published a list of twelve potentially most dangerous priority pathogens with antibiotic resistance in 2017 and emphasized on discovering new antibiotics to tackle these pathogens. ESKAPE pathogens comprising Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa and, Enterobacter species can productively escape the antagonistic effects of the current antimicrobial agents. Urgent discovery of new drugs to tackle these resistant pathogens is required. This chapter mainly focuses on the strategies and methods on discovering novel antibiotics against drug resistant pathogens.

Alternative Approaches to Antimicrobials

Historically, infectious diseases has been a major threat to human and other animals health and an important cause of morbidity and mortality. The introduction of antimicrobials in the first half of the twentieth century revolutionized medicine by substantially reducing morbidity and mortality rates from infectious diseases. Nevertheless, it was soon observed that bacteria could become resistant to antimicrobials, and resistant strains emerged shortly after the introduction of every new antimicrobial drug. Unfortunately, resistance is a natural and unavoidable consequence of antimicrobial use. For this reason, new antimicrobials are urgently needed, but so are additional approaches to protect the value of available antimicrobials. The discovery of a new antimicrobial is not an easy task where the scene is further complicated by a variety of interacting factors. In order to eliminate the spread of antimicrobial resistance, firstly, the inappropriate use should be reduced both in human and veterinary applications and alternative approaches should be considered. Until now, many alternatives, including plant-derived compounds, bacteriophages and phage lysins, probiotics, and into antimicrobial peptides from a variety of sources have been tested especially against resistant strains. These approaches are currently lacking in antimicrobial management, meanwhile, they have demonstrated considerable potential for application in other diseases. The review presents an insight into antimicrobials, particularly direct-food microbial, as well as other alternative products such as plant-derived compounds, bacteriophages and phage lysins, and antimicrobial peptides along with other alternative products, including novel approaches applicable to the field.

Potential Biological Mechanisms with Prophylactic Action in Rapid Cognitive Impairment in Late- Onset Alzheimer's Disease

Given the alarming increase in the Alzheimer's Disease (AD) related costs and the number of patients, significant importance of the research of dementia in elderly people is represented by the early detection of dementia signs and identifying ways to slow down the cognitive decline that should be done by the entire medical community, not only by specialists in psychiatry, neurology and geriatrics. An integrated, multidisciplinary approach can only be achieved by recognizing some clinical-biological parameters that may represent an early signal for a potential onset of AD, or that may speed up the cognitive impairment. Dysfunctional neurobiochemical mechanisms in AD engaging in multimodal pathogenic processes of cognitive impairment, are correlated with the presence of clinical, imaging or biological markers. Identifying risk factors for the progression of cognitive impairment in AD will bring significant improvement in primary and secondary prophylaxis in late-onset AD with improved quality of patient life and a significant decrease in the cost of care associated with this pathology. The patient's assessment should consider multiple somatic comorbidities, associated with cognitive impairment: neurobiochemical vulnerabilities (acetylcholine, dopamine, serotonin and noradrenaline deficiency), traumatic brain injury, disruption of the blood brain barrier, insomnia, depression, cardiovascular diseases, diabetes, hepatic steatosis, infectious pathology. The etiology of late-onset AD and the rapid progression of cognitive decline are complex, multifactorial and incomprehensible, the genetic component is less involved, and is a real challenge for research on the pathology of cognitive impairment. These considerations make it difficult to diagnose early and develop effective therapeutic strategies.

Sjogren’s or Sicca Syndrome and Mikulicz’s Disease or an IgG4-Related Disease

Sjogren’s or sicca syndrome (SS), is a progressive, inflammatory autoimmune disease affecting the exocrine glands. Clinical features include mucosal dryness presented as xerophthalmia (keratoconjuctivitis sicca), xerostomia, xerotrachea and vaginal dryness, major salivary gland enlargement, non-erosive polyarthritis and Raynaud’s phenomenon. The symptoms are mild from dryness of mucosal surfaces in some patients to very severe with involvement of many organs in others. The disease has increased mortality, due to extraglandular systemic involvement and often accompanying lymphoma. Laboratory tests show positive antinuclear antibodies, rheumatoid factor and anti Ro/SSA, anti La/SSB antibodies. Biopsy of the minor salivary glands is a gold standard in the diagnosis of SS. The focus score in an area of 4 mm2 describes focal aggregates of at least 50 lymphocytes. One present focus score represents a positive result. Structural damage on the eye surface is evaluated using the Lissamine green test. Patients with SS have a 44 times higher risk of developing lymphoma than normal control population. Extraglandular symptoms may be treated with GCS and immunosuppresive drugs in severe cases (CYC, AZA or MMF in pulmonary alveolitis, glomerulonephritis or severe neurological features). Mikulicz’s disease (MD) is an IgG4-related disease. Criteria of MD are: increased IgG4 level (>135 mg/dl), tissue biopsy with infiltration of IgG4 plasmocytes with fibrosis and sclerosis. Differences between MD and SS: MD does not show the same female predominance. Allergic rhinitis and autoimmune pancreatitis are seen more often in MD. There is an increased improvement after GCS treatment in patients with MD than with SS.

Systemic Fungal Infection

Fungi are responsible for approximately 10% of nosocomial infections, with Candida spp. being the most prevalent etiological agent. Immunocompromised individuals are more susceptible to fungal infections. An early determination of the etiology of the infection is extremely important for these patients because it provides valuable information for choosing the best therapeutic scheme and may increase the chances of recovery. Due to the low sensitivity of direct examination, the determination of the etiology of a fungal infection often requires culture of biological specimens for isolation and identification of the disease causative agent. Blood culture is not effective for diagnosis of invasive fungal infections, even when serial specimens are analyzed. Serological identification of fungal cell wall proteins (galactomannan, mannan, β-glucan) are considered the first line diagnosis of invasive fungal infections; however, it has low sensitivity because the antigens are rapidly removed from the bloodstream. Molecular biology diagnostic methods have been developed as an alternative for the - detection of fungal infections that are difficult or impossible to detect by conventional microbiological and serological methods. In this chapter, we provide an up-to-date review of nosocomial fungal infections, focusing on the occurrence, etiology, risk factors, clinics, as well as the conventional and molecular methods of diagnosis. We also discuss the use of molecular markers for the detection of fungal infection.

Sepsis: Traditional and Emergent Biomarkers for Diagnosis and Prognosis

Sepsis and its related complications are associated with significant morbidity and mortality among populations worldwide. Early diagnosis and prompt initial management are keys to improve sepsis outcome. Therefore, biological markers (biomarkers) can be useful for identifying or ruling out sepsis, identifying patients who may benefit from specific therapies or assessing the response to therapy. Although numerous biomarkers have been investigated, only two biomarkers are currently used in the clinical practice, C-reactive protein (CRP) and procalcitonin (PCT). Both were included in 2001 in the revised definition of sepsisas variables to diagnose sepsis, but even these have limited ability to distinguish sepsis from other inflammatory conditions or to predict outcome, and there is a continuous search for better biomarkers of sepsis. Moreover, the recent Third Consensus Definitions for Sepsis and Septic Shock does not include the use of biomarkers as tools for management of sepsis and, probably, to redefine the role of these biomarkers is necessary. The purpose of this review is to describe the most relevant sepsis biomarkers used currently in the clinical practice and discuss the future role of some emergent biomarkers for the management of sepsis.

Early Neonatal Sepsis Biomarkers

Early-onset neonatal sepsis is currently a major cause of morbidity and mortality in neonatal period and its rapid diagnosis can help to establish an effective antibiotic treatment. The suspicion diagnosis of neonatal sepsis is based on a number of risk factors and non-specific clinical and laboratory parameters, therefore in many cases it is difficult to assess when it is the proper period to initiate antibiotic treatment. Confirmatory diagnosis depends on the results of blood cultures in the neonatal period, hence the importance of a biochemical marker that allows predicting the likelihood infection, as well as supporting the diagnosis of sepsis. Therefore identifying tools for rapid detection of neonatal sepsis is an objective of great importance in perinatal medicine, as an early and accurate diagnosis leads to an appropriate treatment thus potentially improving the final prognosis of these patients. The objective of this work is to study different markers of early neonatal sepsis, biochemical and haematological, particularly in cord blood; and establish its potential clinical usefulness. New techniques of molecular biology in cord blood are being studied in different types of samples, both blood and neonatal cord blood.

Alternative Anti-Infective/Anti-Inflammatory Therapeutic Options for Fighting Alzheimer’s Disease

Neurodegenerative diseases (NDs) have a serious impact on global health with no effective treatments yet available. Alzheimer's disease (AD) is an incurable, progressive neurodegenerative disorder, considered to be the most common cause of dementia. There is increasing evidence for the infectious/inflammatory etiology of AD. Although brain is assumed to be an immunologically isolated organ, many bacteria (Helicobacter pylori), viruses (Herpes simplex virus, influenza, CMV etc.), fungi, toxoplasma, are associated with AD. The presence of immune-related antigens around amyloid plaques, activated complement factors, cytokines and a wide range of related receptors in the brain of AD patients, led to the concept of “neuro-inflammation”. Persistent or acute neuronal and peripheral inflammatory response to infectious agents is gradually gaining more attention, as a risk factor for someone to develop sporadic AD. The human microbiome (HM) has a pivotal role in nutrition, health and disease. About 100 trillion bacteria from up to 1000 bacterial species inhabit the gastrointestinal (GI) tract, contributing, at least in part, to what is known as the “human-biochemical” or “genetic-individuality” and resistance to disease. Several pathologies, including AD and inflammatory bowel disease, are associated with alterations in gut microbiome. Microbes of the gut microbiota or of extracorporeal origin possess the ability of producing functional amyloid proteins. These amyloids, via lymphatic and systemic transport to the Central Nervous System (CNS), seem to have an important role in the expression of neurologic and psychiatric disorders, such as schizophrenia, anxiety and AD. Cross-seeding of the neurodegenerative disorder proteins may be induced by these amyloids. Moreover, chronic inflammatory response to these immune-reactive proteins can also be an important risk factor for CNS well-being. Therapeutic/preventive options for halting CNS disorders’ onset, could include: (a) Anti-inflammatory, anti-amyloid drugs (β-sheet breakers and other inhibitors of amyloid fibrillization), monoclonal antibodies, nanoparticles, which target pathological components of AD, or other medical interventions to remove infectious agents or to ameliorate their biochemical influence on GI-CNS tract, (b) Prebiotics to enhance the growth of desired organisms and reduce oxidative stress - a cause that has been implicated with AD, (c) Probiotics to provide both the desired bacteria, which increase the competitive effects with pathogens, and essential metabolic products, and to modulate the host immune system to resist in infection (d) The consumption of natural products, and the dedication to the Mediterranean (MeDi) and Asian (AsDi) Diets, abundant in bioactive compounds, are capable to prevent AD or reduce danger of AD, and strengthen the host's ability to confront infections. The significance of diet diversity leading to the microbiota diversity is a new clinically important concept. Finally, and (e) preventive medical and/or other therapies to alter the amyloids produced by bacteria, to decrease their production or stimulate their removal. This chapter is addressed to, and urges the excellent cooperation between experts of neurology/psychiatry, microbiology, biochemistry, dietary and nutritional sciences, in order to confront AD.

Iatrogenic Lesions in Neurology

Iatrogenic neurological disorders can be induced by several factors, such as pharmacological agents prescribed for treatment or prevention (drug-induced neurological disorders [DIND]), complications of diagnostic and treatment procedures, like cerebral angiography or lumbar puncture, organ transplantation (related to the surgical procedure of transplantation, post-transplant immunosuppression, opportunistic infection or the inherent disorders that lead to transplantation), radiation therapy, etc. Iatrogenic neurological effects may be devastating due to the higher potential irreversibility of central nervous system, peripheral nervous system, neuromuscular junction (NMJ) and/or muscular system involvement. DIND represent the majority of iatrogenic neurological disorders. Drugs may directly induce neurological damage (through primary neurotoxicity, such as damage to the bloodbrain barrier [BBB], disturbances of brain energy metabolism, ion channels/neurotransmitters disturbances, mitochondrial dysfunction, metabolitemediated toxins, drug-induced selective cell death) or do so indirectly (cardiovascular, hematological or renal effects). Identification of DIND is important because early recognition and drug withdrawal can prevent irreversible damage. The numerous intrinsic risk factors for DIND should be well known by medical practitioners.

Free-living Amoebae

Acanthamoeba Species is the most common free living amoeba present in environment. It is isolated from soil, water, contact lens solutions, transplant units and various other hospital environment. There are many species of Acanthamoeba such as A.astronyxis, A.castellani, A.culbertsoni, A.hatchetti, A.keratitis etc. which are known to cause opportunistic infection in both immunocompetent as well as immunocompromised host. Transmission mainly occurs through direct contact. There are two described morphological forms; a trophozoite form and a cyst form. The trophozoites have characteristics pointed thorn like acanthapodias, containing one nucleus with central dense large nucleolus. The cytoplasm measures between 15-50μm, granular and contains various organelles. Clinically patients usually presents with granulomatous amoebic encephalitis (GAE) which is characterized by focal neurological deficit, headache, visual disturbances, seizures and behavioral abnormalities which develops over months to years. Laboratory diagnosis of Acanthamoeba spp. is done by examining CSF which generally shows predominant lymphocytes, elevated proteins and low glucose levels. Histopathological samples of the brain generally reveals cerebral edema, multiple necrotic and hemorrhage lesions. Acanthamoeba can easily be cultivated on non-nutrient agar with overlay of Escherichia coli or Entrobacter spp. Amoeba feeds on bacteria’s and confluent growth is seen in 4-5 days of culturing. The combination therapy is advisable in proven cases of Acanthamoeba infection. Combining Amphotericin B plus Trimethoprim- Sulphamethoxazole plus rifampicin has successfully used in few cases.

Naegleria Fowleri: The organism was first reported in Australia in 1965. It is an environmental ameboflagellate parasite found in variety of water bodies such as ponds, swimming pools; aquarium etc. prefers temperature of 30-45ºC. There are three stages seen in Naegleria life cycle: the infective trophozoites, transient flagellated and the resistant cystic stage. The portal of entity of trophozoites is via olfactory neuroepithelial cell lining covering the cribriform plate to reach olfactory bulb. Demyelination and myelinoclasis are observed in gray matter due to vascular blockage. These pathological changes are attributed to release of phospholipolytic enzymes which causes breaks in the lipid membrane of neuronal cells. Clinically, patients of primary amoebic meningoencephalitis (PAM) usually presented with high grade fever,headache, photophobia and features of raised intracranial pressure. Laboratory diagnosis is done using peripheral smear, CSF examination, culture, histopathological examination and imaging modalities. Hematological findings are leukocytosis with predominant neutrophils. The CSF shows low glucose and high protein levels. Centrifugation of fresh CSF sample up to 500 RPM may reveal motile trophozoites. Morphologically, the size of trophozoites ranges between 12-25μm, with a single nucleus and centrally placed nucleolus in the absence of peripheral chromatin. Liquid culture media such as such as Nelson’s medium containing ox liver digest and glucose are used with serum for growing amoebae. Mammalian cell lines can be employed to demonstrate cytopathic effect. Multiplex PCR detects free living amoeba within 6 hours but routine use in diagnostic laboratory is limited due to rarity of finding these organisms and having high cost of PCR. Brain imaging is easy to perform but restricted by nonspecific findings such as cerebral edema. Specifically, infraction involving frontal, orbital and cerebellum area can be observed in few cases of PAM. There is no optimal treatment regime for Naegleria fowleri. Literature suggests combination therapy works best with amphotericin, rifampicin and azithromycin.

Balamuthia Mandrillaris: Over 200 cases were reported from South America and United States. The true prevalence of disease is unknown in south East Asia. Organism is commonly isolated from soil contact with activities related to soil such as gardening, agriculture pose risk of acquiring the organism. It was first isolated in 1986 from baboon brain that died of meningoencephalitis. The portal of entry of the organism is via cutaneous lesions, nasal mucosa and then subsequent spread to brain. CNS lesions mimic acanthamoeba encephalitis and have chronic slowly progressive course over many years. The life cycle of Balamuthia involves two stages: trophozoites and the cyst. The morphologically variable trophozoites are 12- 60 microns in size containing single nucleus with large centrally placed nucleolus. Cysts are spherical in shape measuring 12-30μm and contain a single nucleus with double wall having outer ectocyst, middle fibrillar layer and inner amorphous endocyst.The trophozoites, cysts and inflammatory cells are observed in perivascular regions of the infected tissue. In CSF, elevated protiens, reduced glucose are common findings. Balamuthia spp. can be grown in tissue cultures such as Monkey Kidney cell lines, Human Lung fibroblast and Human Brain Microvascular Endothelial cell lines. ELISA test is very specific to detect high antibodies titers. The antibodies do not cross react with other free living amoebae. PCR is also highly specific and sensitive test in which primers are developed against mitochondrial rRNA genes. Recently, real time PCR are developed targeting RNAase P gene of B.mandrillaris.

Sappinia Species: Two species of Sappinia are well-known cause of CNS infections in humans, Sappinia diplodea and Sappinia pedata. S.diploidea was first isolated from lizard faeces. As this parasite is found in animal faeces, persons handing livestock are at higher risk. Only one known case of Sappinia encephalitis infection reported in literature. The diagnosis was confirmed on histopathological sample, which showed necrotizing haemorrhagic inflammation of infected tissue, containing trophozoites. The trophozoite of Sappinia is characterized by two opposing nucleus with central flattening. Diagnosis can also be done by amplifying rDNA of both Sappinia diploidea and Sappinia pedata using SSU primers. The real time PCR can also be used based on 18rRNA gene sequences. Sappinia spp. is cultivated on non- nutrient agar with overlay of Enterobacter or Escherichia coli. Vahlkamphia spp. and Paravahlkamfia francinae are other emerging free living amoebas that were first isolated from CSF of young patient who presented with typical symptoms of primary amoebic meningoencephalitis.

Essential Oils, Polyphenols and Glycosides: Secondary Plant Metabolites against Human Pathogenic Microbes

Higher plants produce secondary metabolites involved in defense mechanisms against herbivores, pests and pathogens. These phytochemicals have also potential healthy properties on human organism, including antioxidant, antiinflammatory and anti-microbial. The pressure to discover and develop new and effective anti-infectious substances has grown due to the intensification of new and reemerging infectious diseases as well as the increasing resistance to the antibiotics in current clinical use. There are several approaches to control diseases caused by microorganisms, and one of them is the use of natural bioactive chemicals that can combat the infection. The essential oils, polyphenols and glycosidic glucosinolates extracted from various species (e.g. medicinal and aromatic plants) have shown promising anti-microbial activity against several pathogens responsible for human diseases. Some of these diseases include mouth diseases as periodontitis, urinary infections, acne, stomach cancer and ulcers associated with Helicobacter pylori, wound infections and gastric infections. Beyond the in vitro and in vivo studies, several compounds from the plant secondary metabolites have been subjected to clinical trials in order to validate their efficacy as anti-infectives (e.g. proanthocyanidins, a polyphenol, that have been tested against periodontitis or tea tree oil 4% against methicillin-resistant Staphylococcus aureus – MRSA) for future prescription. As most of these compounds have poor water solubility and are easily oxidized a chemical transformation which may alter their anti-infective properties, new strategies are being considered both to protect these phytochemicals against oxidation and to enhance their bioavailability and delivery to the desired organs. This chapter summarizes and discuss the most promising phytochemicals that are being used to treat human diseases, antimicrobial mechanisms, the results of clinical trials and the new approaches based on nanoencapsulation strategies to deliver and target these compounds in vivo.

Uncommon Cause of Stroke: Diagnosis and Treatment (Part I)

This chapter contains detailed, up-to-date information about the nature, diagnosis, and treatment of those relatively uncommon types of cerebrovascular disease that cause strokes. Although many of the conditions discussed are rare, the chapter covers the causes of up to 10% to 15% of all strokes and of up to 40% of strokes in young adults. This chapter may be an essential resource to help physicians diagnose and treat stroke patients who do not fit well into the usual clinical categories.

Discussed within are the dissection of carotid and vertebral arteries, the more relevant cause of stroke in the young. The collagen vascular disorders causing stroke as a consequence of dissection , occlusion and, more rarely, rupture of extracranial and intracranial arteries are reported in detail. Various forms of cerebral angiitis, with focus on the primary central system vasculitis and reversible cerebral vasoconstriction syndrome are discussed.

Microbial and Parasitic Diseases of Fish

Diseases of fish, caused by biological agents (bacteria, fungi, virus or parasites), are better known in farmed or ornamental fish, since the access to the affected fish coming from the natural environment is less probable. In fact, the fish that are infected by a specific pathogenic agent, natural inhabitants of the marine, estuarine or freshwater ecosystems, are rapidly eliminated from its biotopes by other predatory animals, due to its higher vulnerability and susceptibility to the social interactions.

Diffusion of pathogenic bacteria, fungi, virus or parasites in the aquatic environments is more efficient than in the terrestrial ones. Diagnosis and therapeutics of fish disease have specific difficulties and the application of preventive measures is a very complex issue. Some of those diseases have the same epidemiological problems of the infectious diseases of the terrestrial animals: High spread of diffusion, very significant economic losses, restrictions to fish travel or commerce and some (few) have zoonotic impacts.

Neuroinflammation

Neuroinflammation is a ubiquitous component of central nervous system (CNS) response to injury. In addition to the disorders traditionally considered inflammatory in nature, neuroinflammation contributes to CNS response in ischemic, traumatic and neurodegenerative disorders. Depending on the particular disorder, both innate and adaptive immune responses may contribute to neuroinflammation. This chapter outlines the basic mechanisms relevant to CNS inflammation. The cells of the CNS innate immune response, including microglia, astrocytes, their mechanisms of activation and innate effector mechanisms such as the production of reactive oxygen and nitrogen species and cytokines are discussed. Features unique to the CNS such as the blood-brain barrier and other mechanisms of CNS immune privilege are outlined. Cells and mechanisms of CNS adaptive immune response such as T lymphocytes, B lymphocytes, activation and effector mechanisms are discussed.

Session Lectures

Sialic Acid Recognition, Removal and Surface Presentation: Role in Microbial Pathogenesis of Human Hosts

Sialic acids (Sia) play a role in the survival of microbes within the diverse environments that both pathogenic and non-pathogenic microbes inhabit. 3-Deoxy-Dmanno- oct-2-ulosonic acid (KDO) and 2-keto-3-deoxynononic acid (KDN) are crucial for the survival of almost all bacterial species, while other Sia are a favourite target for viruses and other host adapted pathogens when interacting with host tissues that are required for survival/replication of the microbe. All pathogenic microbes, whether bacteria, viruses, parasites, or fungi, must be able to specifically interact with host cells/tissues to initiate disease. The success of these pathogens at maintaining a disease state relies on the ability of these organisms to subvert or evade the host immune responses. In this chapter we will discuss the ways in which Sia, Neu5Ac specifically, is crucial for the ability for many human pathogens to cause and maintain disease.

Infectious Complications of Kidney Transplantation

Improved immunosuppressive therapies for organ transplantation have reduced the incidence of allograft rejection while increasing susceptibility to opportunistic infections and virally mediated malignancies. Renal transplant recipients are susceptible to a broad range of infectious pathogens and infections often progress rapidly. Improved microbiologic diagnostic tools are used in the routine management of common infections and have allowed the definition of new clinical syndromes and of donor-derived infections. However, invasive diagnostic procedures are often required for accurate and timely diagnosis and are justified by the high morbidity and mortality of infection in this population. Early and specific microbiologic diagnosis is essential for guiding treatment and minimizing nonessential drug therapy.

Graft-Transmitted Infection in Kidney Transplantation

Transplanted organs can transmit infectious diseases to recipients with varying consequences depending on the pathogen, the infection status of the recipient and the effectiveness of treatment (curative and/or preventive). In this non-exhaustive review, we detailed the classical diseases transmitted by the transplanted kidney which can be easily detected in the deceased donor with the last recommendations of treatment, but also emerging infectious diseases due to the increasing mobility of populations (conventional tourism , transplant tourism, immigration .). New challenge in this field, is the earliest possible detection of infectious agents from the donor to guide the decision of organ harvesting and direct matching D/R . Pending the use of Nucleic Acid Testing in routine, it remains essential, in addition to conventional serological tests, to achieve a very specific examination, paying particular attention to record the countries visited by the donor, as well as performing systematic bacteriological and mycological analysis of preservation solution.

Index

Sporothrix schenckii and General Aspects of Sporotrichosis

The thermally dimorphic fungus Sporothrix schenckii is the etiological agent of human and animal sporotrichosis and belongs to the recently proposed Sporothrix complex, which includes other species based on the phylogenetic-species concept. Sporotrichosis is a deep mycosis and clinical manifestations vary from a benign lymphocutaneous form to less frequent disseminated and extracutaneous forms, mainly associated with an immunocompromised host. Animals are also susceptible to S. schenckii infection and cats (Felis catus) are known for greater predisposition to this fungal infection. Only recently has zoonotic transmission of this disease been reported in greater detail in the literature and these new data are changing the epidemiological concept of this mycosis. The gold standard for the diagnosis of sporotrichosis remains fungus isolation from biological specimens, but new diagnostic tools are under development for both human and animal sporotrichosis. The outcome of an infectious disease is not only associated with virulence factors inherent to the pathogen, but also the host immune response. Thermotolerance is described as a virulence factor for S. schenckii and is associated with the capacity of a clinical or environmental isolate to cause host damage. However, the description of new species and genotypes among clinical isolates and the observation that thermotolerant isolates can exhibit differences in virulence using in vivo models strongly supports the concept that other virulence factors could be related to the clinical manifestations or modulate the host immune response. This chapter will address new data in relation to the clinical, epidemiological and biological aspects of S. schenckii.

Meningitis & Encephalitis

Infections of the meninges (meningitis) and the brain (encephalitis) needs to be identified and managed promptly in order to prevent associated morbidity and mortality. Symptoms and signs of raised intracranial pressure are frequently the initial features of meningitis caused by bacterial or viral infections. Encephalitis is more frequently caused by viral infections with features that include seizures, personality change, decreased consciousness, and focal neurological manifestations. As the infection progress, mixed features are frequently encountered (meningoencephalitis). In this chapter, an updated overview of meningitis and encephalitis in infants and children is presented.

Cell-Penetrating Peptides and Protein Transduction Domains in Drug Delivery

High molecular weight biomolecules are becoming increasingly important for the development of molecular therapies. However, these molecules cannot diffuse through the cell membrane the way traditional small molecule drugs can. The potential therapeutic use of such information-rich macromolecules has been limited by their poor permeability across the lipid bilayer of biological membranes. Different approaches have been used to develop biological agents, biophysical methods or mimicking natural processes to overcome the barrier function of the plasma membrane. The unique capability of special oligopeptides, known as cellpenetrating peptides (CPPs) or protein transduction domains (PTDs), opened the way to introducing biologically active macromolecules into living cells. These peptides, conjugated or complexed with the desired molecules, can be used in both in vitro and in vivo systems for the intracellular or intraorganellar delivery of large molecules. After the discovery of these small peptides, macromolecular transport across biological membranes has emerged as a valuable technique in basic research and a promising tool in in vivo preclinical models and clinical trials. This chapter attempts to give an overview of what kind of CPPs exist, how they function, what has been achieved and what can be achieved in the future with their use. It also aims to expose the limitations of the utilization of CPPs and the controversies regarding their potential, working mechanism and route of internalization. Finally, we want to discuss how virus-, liposome- and CPP-mediated techniques converge into new complex methodologies.