Community-acquired pneumonia in patients with and without chronic obstructive pulmonary disease.

PURPOSE: The purpose of this study was to analyse the possible differences, especially those regarding mortality, between patients hospitalized for community-acquired pneumonia (CAP) with and without chronic obstructive pulmonary disease (COPD), and the risk factors related to mortality in the COPD group. METHODS: 710 patients with CAP were included in a prospective multicenter observational study. 244 of the patients had COPD confirmed by spirometry. RESULTS: COPD was associated with mortality in patients with CAP (OR=2.62 CI: 1.08-6.39). Patients with COPD and CAP had a significantly higher 30-day mortality rate as compared to patients without COPD. Multivariate analysis showed that PaO(2)< or =60 mmHg (OR=7.95; 95% CI: 3.40-27.5), PaCO(2)> or =45 mmHg (OR=4.6; CI: 2.3-15.1); respiratory rate > or =30/min (OR=12.25; CI: 3.45-35.57), pleural effusion (OR=8.6; 95% CI: 2.01-24.7), septic shock (OR=12.6; 95% CI: 3.4-45.66) and renal failure (OR=13.4; 95% CI: 3.2-37.8) were significantly related to mortality. Purulent sputum and fever were considered as protective factors. CONCLUSIONS: COPD was an independent risk factor for mortality in patients with CAP. Hypoxemia and hypercapnia are associated with mortality in patients with CAP with and without COPD. Chronic obstructive pulmonary disease and PaCO(2) value could be useful prognostic factors and should be incorporated in risk stratification in patients with CAP.

Enterocyte actin autoantibody detection: a new diagnostic tool in celiac disease diagnosis: results of a multicenter study.

OBJECTIVES: This study describes a new method to detect autoantibodies against actin filaments (AAA) as a serological marker of intestinal villous atrophy (IVA) in celiac disease (CD), and reports the results of an Italian double-blind multicenter study. METHODS: IgA-AAA were analyzed by immunofluorescence using a newly developed method based on intestinal epithelial cells cultured in presence of colchicine. IgA-AAA were blindly evaluated prospectively in 223 antiendomysial antibody (AEA) and/or antitransglutaminase antibody (TGA) positive subjects and in 78 AEA and TGA negative subjects. IgA-AAA positive patients underwent an intestinal biopsy to confirm the diagnosis. Moreover, IgA-AAA were retrospectively investigated in 84 biopsy-proven CD patients and in 2,000 new consecutively collected serum samples from AEA and TGA negative nonbiopsied subjects. RESULTS: IgA-AAA were positive in 98.2% of the CD patients with flat mucosa, in 89% with subtotal villous atrophy, and in 30% with partial villous atrophy. IgA-AAA were present in none of the AEA and TGA negative nonbiopsied controls. In AEA and/or TGA positive CD patients IgA-AAA positivity significantly correlated with IVA (p < 0.000 in the prospective study, p = 0.005 in the retrospective study). In the prospective study, the values of sensitivity, specificity, the positive predictive value, the negative predictive value, and the efficiency of the IgA-AAA test to identify patients with IVA were, respectively, 83.9%, 95.1%, 97.8%, 69.2%, and 87.0%. Furthermore, a significant correlation (p < 0.0001) was found between the IgA-AAA serum titre and the degree of IVA (rs 0.56). CONCLUSIONS: The results of this multicenter study show that the new method for IgA-AAA detection could represent a practical diagnostic tool in AEA and/or TGA positive subjects, which would be especially useful when IVA shows a patchy distribution, when the histological picture is difficult to interpret, or when a biopsy could represent a life-threatening risk.

Early effects of gliadin on enterocyte intracellular signalling involved in intestinal barrier function.

BACKGROUND AND AIMS: Despite the progress made in understanding the immunological aspects of the pathogenesis of coeliac disease (CD), the early steps that allow gliadin to cross the intestinal barrier are still largely unknown. The aim of this study was to establish whether gliadin activates a zonulin dependent enterocyte intracellular signalling pathway(s) leading to increased intestinal permeability. METHODS: The effect of gliadin on the enterocyte actin cytoskeleton was studied on rat intestinal epithelial (IEC-6) cell cultures by fluorescence microscopy and spectrofluorimetry. Zonulin concentration was measured on cell culture supernatants by enzyme linked immunosorbent assay. Transepithelial intestinal resistance (Rt) was measured on ex vivo intestinal tissues mounted in Ussing chambers. RESULTS: Incubation of cells with gliadin led to a reversible protein kinase C (PKC) mediated actin polymerisation temporarily coincident with zonulin release. A significant reduction in Rt was observed after gliadin addition on rabbit intestinal mucosa mounted in Ussing chambers. Pretreatment with the zonulin inhibitor FZI/0 abolished the gliadin induced actin polymerisation and Rt reduction but not zonulin release. CONCLUSIONS: Gliadin induces zonulin release in intestinal epithelial cells in vitro. Activation of the zonulin pathway by PKC mediated cytoskeleton reorganisation and tight junction opening leads to a rapid increase in intestinal permeability.

[Community-acquired pneumonia in the elderly: prognostic factors]. / Neumonía adquirida en la comunidad en el anciano. Factores pronósticos.

The incidence and mortality rates of community-acquired pneumonia are far higher in the elderly than among younger populations. However, the explanation may lie in the presence of comorbidity rather than in age itself. We performed a retrospective study of 226 patients over the age of 65 years who were admitted to our hospital with a diagnosis of community-acquired pneumonia over a period of 36 months, with the objective of identifying factors predicting mortality and to describe clinical features. The patients' mean age was 78.71 (65-96) years. One hundred forty-two were men (63%) and 84 were women (37%). Upon admission, 27.4% showed signs of altered mental state. The crude mortality rate was 20.8%. Multivariate analysis demonstrated the following independent risk factors associated with higher mortality: serum creatinine > 1.2 mg/dL (RR = 13.93; 95% CI 8.14-16.08); patient previously bedridden (RR = 5.73; 95% CI 3.41-6.79), PaO2/FiO2 < 200 (RR = 5; 95% CI 2.67-6.62) and neoplastic disease (RR = 4.08; 95% CI 1.96-5.24). The presence of chest pain was associated with a lower risk of mortality (RR = 0.11; 95% CI 0.01-0.54). Age itself was not a risk factor. We conclude that pneumonia in the elderly requires hospitalization and that it commonly presents with severe symptoms and high risk of mortality. Risk factors such as those identified in this study may help in the diagnosis and treatment of patients requiring special care.

Neumonía adquirida en la comunidad en el anciano. Factores pronósticos / Community-acquired pneumonia in the elderly: prognostic factors

La incidencia de la neumonía adquirida en la comunidad (NAC) en el anciano y su mortalidad es muy superior con respecto a la población joven. Sin embargo, esto puede explicarse por la presencia de comorbilidad concomitante más que por la edad por sí sola. Nosotros realizamos un estudio retrospectivo de 226 pacientes de edad superior a 65 años que fueron ingresados en nuestro hospital con el diagnóstico de NAC durante un período de 36 meses con el fin de valorar factores pronósticos de mortalidad en este grupo de población y describir, asimismo, las características clínicas. La edad media fue de 78,71 (límites 65-96) años. Un total de 142 pacientes fueron varones (63 por ciento) y 84 mujeres (37 por ciento). En el momento del ingreso, el 27,4 por ciento de los pacientes presentaban alteración del estado mental. La mortalidad cruda fue del 20,8 por ciento. El análisis multivariante demostró algunos factores de riesgo independientes asociados con mayor mortalidad: creatinina sérica > 1,2 mg/dl (riesgo relativo [RR]: 13,93; intervalo de confianza [IC] 95 por ciento: 8,14-16,08), encamamiento previo (RR: 5,73; IC del 95 por ciento: 3,41-6,79), PaO2/FiO2 < 200 (RR: 5; IC del 95 por ciento: 2,67-6,62) y enfermedad neoplásica (RR: 4,08; IC del 95 por ciento: 1,96-5,24). La presencia de dolor torácico se asoció con un riesgo menor de mortalidad (RR: 0,11; IC del 95 por ciento: 0,01-0,54). La edad por sí sola no fue un factor de riesgo relacionado con el pronóstico. Concluimos que la neumonía en el anciano que requiere hospitalización se presenta en muchas ocasiones con clínica severa y alta mortalidad. Los factores pronósticos como los objetivados en este estudio pueden ayudar al clínico a evaluar aquellos pacientes que requieren cuidados especiales. (AU)

Hepatitis B virus infection in native versus immigrant or adopted children in Italy following the compulsory vaccination.

BACKGROUND: Compulsory vaccination of children against hepatitis B virus (HBV) infection was introduced in Italy in 1991. PATIENTS AND METHODS: To evaluate the current importance of pediatric HBV infection, we studied 359 HBsAg-positive children admitted to 16 centers in Italy from 1991 to 1998. 185 patients were natives of Italy and 174 (39 immigrants and 135 adopted) came from highly endemic countries (eastern Europe: 60.9%, Asia: 16.7%, Africa: 14.9% and Central and South America: 5.7%). RESULTS: Transaminase Levels were moderately altered in both Italian (mean 134 UI/L) and foreign children (mean 168 UI/L). In total, 77% of ItaLian children and 88% of foreign children tested HBeAg positive. High transaminase levels and HBeAg positivity were more frequent in adopted children. Follow-up of 317 patients showed that the incidence of HBeAg/anti-HBe serum conversion was similar in all cohorts, but in adopted children it occurred at an earlier age and was associated with HBsAg clearance in 5%. CONCLUSION: HBV is not frequent in Italian children today, but it is common among children coming from highly endemic areas. The vaccination of nonimmune native populations must be strongly recommended.

Organ-specific and non-organ-specific autoantibodies in children and young adults with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED).

OBJECTIVE: The aim of the study was to assess the complex of autoantibodies which can be detected in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a rare autosomal recessive disease in which the extent of autoimmunity is still unknown. DESIGN: Antibodies (A) to parathyroid glands, adrenal cortex (AC-A), ovary and testis (steroid cell antibodies, SC-A), pancreatic islet cells (IC-A), gastric parietal cells, and non-organ-specific antigens were investigated in 11 APECED patients living in the Salento region of southern Italy. Further measurements included antibodies to cytochrome P450 (CYP) enzymes: cholesterol side-chain cleavage enzyme (CYP11A), 21-hydroxylase (CYP21) and 17alpha-hydroxylase (CYP17); and to glutamic acid decarboxylase 65-kDa isoform (GAD65), tyrosine phosphatase-like protein IA2, thyroglobulin (TG), thyroperoxidase (TPO), thyrotropin receptor, liver CYP enzymes and intrinsic factor. METHODS: Antibodies to organs and subcellular fractions were detected by immunofluorescence. Radiobinding, immunoradiometric, and immunoblotting assays were used for the other measurements. RESULTS: AC-A and SC-A were positive in all sera; among antibodies to adrenal CYP enzymes, only CYP21-A were present in all the patients with Addison's disease of short-medium duration (<15 years). Of three patients with Addison's disease of long duration (>15 years), two tested positive for antibodies to all three CYP enzymes, and the other for only CYP11A-A. In all sera CYP11A-A and/or CYP17-A were found. Two patients tested positive for both IC-A and GAD65-A, one for both IC-A and IA2-A, and one for GAD65-A; the fasting C-peptide assay showed no statistical difference between these four subjects and the others. All four hypothyroid patients were positive for TPO-A, while two of them were positive and two were negative for TG-A; two euthyroid subjects had positivity for TG-A. Liver-kidney microsomal antibodies reacting against the CYP2A6 were detected in two patients with autoimmune hepatitis. All but one sera contained anti-nuclear antibodies at a titre ranging between 1:20 and 1:80; however, only two patients had a connective tissue disease (Sjögren's syndrome). CONCLUSIONS: Several autoantibodies may be detected in any APECED patient. Our data confirm that CYP21-A and TPO-A are major autoantibodies involved in APECED-associated Addison's disease and hypothyroidism respectively, while CYP11A-A and CYP17-A correlate with positivity for SC-A. Markers of islet cell autoimmunity are frequent, but prevalence and modalities of progression to overt beta-cell failure have to be clarified. Low-titre non-organ-specific autoantibodies are a feature of autoimmunity in APECED, but their role has yet to be fully explained.

Autoantigen characterization in liver/kidney microsome positive hepatitis.

Liver/kidney microsome autoantibodies are detectable in different forms of chronic hepatitis, namely autoimmune, viral, and drug-induced hepatitis and in hepatitis associated with Type 1 autoimmune polyglandular syndrome. Based on the aetiology of chronic hepatitis, liver/kidney microsome autoantibodies are directed against different enzymes with very little overlap. Thus, the simple Indirect Immunofluorescence test, which is universally used as a screening test to detect autoantibodies, does not allow subtyping of liver/kidney microsome autoantibodies. This brief review stresses the need to use methods such as Western-Blotting and enzyme-linked immunosorbent assay together with Indirect Immunofluorescence to characterize the liver/kidney microsome autoantibodies. Identification of the liver/kidney microsome target antigens, when possible, makes differential diagnosis easier and, at times, may help the clinician to choose the best approach to treatment.

Immune reaction against the cytoskeleton in coeliac disease.

BACKGROUND: The cytoskeleton actin network of intestinal microvilli has been found to be rapidly impaired after gluten challenge in coeliac disease (CD). The aim of this study was to investigate the presence of an immune reaction towards cytoskeleton structures such as actin filaments in CD. METHODS: Eighty three antiendomysial antibody positive CD patients (52 children and 31 adults) were studied at our outpatient clinics from 1996 to 1998 using indirect immunofluorescence, ELISA, and western blotting for antiactin (AAA) and antitissue transglutaminase (TGA) antibodies before and after a gluten free diet (GFD). Sixteen patients with smooth muscle antibody positive autoimmune hepatitis, 21 with inflammatory bowel diseases, seven with small bowel bacterial overgrowth, and 60 healthy subjects were studied as controls. RESULTS: Fifty nine of 83 CD patients (28/31 adults (90.3%); 31/52 children (59.6%)) were positive for IgA and/or IgG AAA. Seventy seven (92.7%) were positive for IgA TGA. IgA AAA were strongly correlated with more severe degrees of intestinal villous atrophy (p<0.0001; relative risk 86.17). After a GFD, AAA became undetectable within five months. CONCLUSIONS: Apart from the immune reaction against the extracellular matrix, we have described an immune reaction against the cytoskeleton in both children and adults with CD. As AAA are strongly associated with more severe degrees of villous atrophy, they may represent a useful serological marker of severe intestinal atrophy in CD.

Two cytochromes P450 are major hepatocellular autoantigens in autoimmune polyglandular syndrome type 1.

BACKGROUND & AIMS: Liver disease has been described in 10%-15% of patients with autoimmune polyglandular syndrome type 1 (APS-1). After the discovery of cytochrome P450 1A2 (CYP1A2) as a hepatocellular autoantigen in liver-kidney microsomal autoantibody (LKM)-positive patients with APS-1, the investigation of antiliver antibodies was extended to 11 Sardinian patients with APS-1. METHODS: Indirect immunofluorescence and Western blotting analysis were performed to study the antiliver antibodies. RESULTS: Immunofluorescence revealed LKM antibodies in 3 patients with APS-1, 1 of whom died of fulminant hepatitis. Western blotting showed a liver microsomal protein band of approximately 51 kilodaltons in the LKM-positive sera of these 3 patients. Western blotting performed with recombinant cytochrome P450 enzymes allowed the identification of CYP2A6 as a specific target antigen. CONCLUSIONS: LKM antibodies in APS-1 sera are specifically directed against CYP1A2 or CYP2A6, but their diagnostic and prognostic significance for liver disease remain to be determined.

Cytochrome P450 1A2 is a hepatic autoantigen in autoimmune polyglandular syndrome type 1.

Autoantibodies directed against proteins of the adrenal cortex and the liver were studied in 88 subjects of Sardinian descent, namely six patients with autoimmune polyendocrine syndrome type 1 (APS1), 22 relatives of APS1 patients, 40 controls with other autoimmune diseases, and 20 healthy controls. Indirect immunofluorescence, using tissue sections of the adrenal cortex, revealed a cytoplasmatic staining pattern in 4 of 6 patients with APS1. Western blotting with adrenal mitochondria identified autoantigens of 54 kDa and 57 kDa, Western blotting with placental mitochondria revealed a 54-kDa autoantigen. The 54-kDa protein was recognized by 4 of 6 patients with APS1 both in placental and adrenal tissue, whereas the 57-kDa protein was detected only by one serum. Using recombinant preparations of cytochrome P450 proteins, the autoantigens were identified as P450 scc and P450 c17. One of six APS1 patients suffered from chronic hepatitis. In this patient, immunofluorescence revealed a centrolobular liver and a proximal renal tubule staining pattern. Western blots using microsomal preparations of human liver revealed a protein band of 52 kDa. The autoantigen was identified as cytochrome P450 1A2 by use of recombinant protein preparations. P450 1A2 represents the first hepatic autoantigen reported in APS1. P450 1A2 usually is not detected by sera of patients with isolated autoimmune liver disease and might be a hepatic marker autoantigen for patients with APS1.

Molecular analysis of patients of Sardinian descent with Crigler-Najjar syndrome type I.

This study reports the molecular characterisation of the bilirubin UDP-glucuronosyl-transferase gene (UGT1) in a group of patients of Sardinian descent with Crigler-Najjar syndrome type I and their relatives. Sequence analysis of both UGT1A exon 1 and common exons 2-5 was performed in all patients, leading to the detection of AF170 and a novel mutation (470insT), both residing in UGT1A exon 1. All but two heterozygotes for the AF170 mutation showed normal serum bilirubin levels. These two subjects were also heterozygous for the sequence variation A(TA)7TAA in the promoter region of the UGT1A gene.

HLA class II genes in chronic hepatitis C virus-infection and associated immunological disorders.

To investigate the factors that may confer susceptibility or protection to hepatitis C virus (HCV) infection and to HCV-associated immunological disorders, we designed two studies on 420 Sardinian transfusion-dependent thalassemia patients followed in our department in Cagliari since 1974. The first one was an epidemiological survey aimed to evaluate the prevalence of HCV infection and HCV-associated immunological disorders. In the second study, the distribution of different HLA class II genes was examined by DNA analysis in 116 HCV positive patients, 30 HCV negative patients, and 606 healthy controls. Three hundred fourteen patients became infected with HCV (74.7%) after 5.6 +/- 2.8 years of regular transfusion program. Mixed cryoglobulinemia, purpura, arthritis, proteinuria, decreased complement levels, rheumatoid factor and anti-GOR, smooth muscle antibody (SMA), anti-nuclear antibody (ANA), and liver, kidney microsome (LKM) autoantibodies were significantly more represented in HCV positive patients than in negative ones (P < .05). A significant increase of HLA class II DR2 subtype (DRB1*1601,DQB1*0502) was observed in a group of 30 HCV negative patients who despite 10.3 +/- 2.2 years in a regular blood transfusion program did not show any evidence of HCV infection (Pc < .0092). Our results represent clear evidence for a relationship between HCV infection and immune extrahepatic abnormalities. A gene(s) located in the human major histocompatibility complex (MHC) region may play an important role in conferring protection against HCV infection.

Cryoglobulinemia in transfusion-dependent thalassemia major.

OBJECTIVE: The aim of this study was to determine the frequency of cryoglobulinemia and associated symptoms in transfusion-dependent thalassemia patients at high risk for HCV infection. METHODS: A controlled epidemiological study was used to evaluate the prevalence of clinical, biochemical and immunological abnormalities in a group of 264 HCV-positive and 106 HCV-negative transfusion-dependent thalassemia patients. Haematologic and hepatic function tests were performed according to standard methods. HCV-RNA was detected by PCR analysis. RESULTS: The significant presence of cryoglobulinemia and associated symptoms (purpura, vasculitis, arthritis, asthenia, proteinuria), serum autoantibodies (SMA, anti-GOR, ANA, LKM), low complement and rheumatoid factor were found in HCV-positive compared with HCV-negative patients. CONCLUSIONS: This study demonstrates the role of HCV in inducing cryoglobulinemia and immunological disorders in transfusion-dependent thalassemia patients. HCV infection and associated immune abnormalities are a new clinical aspect of, and deserve particular attention due to their high frequency in, transfusion-dependent thalassemia patients.

Effect of iron overload on the response to recombinant interferon-alfa treatment in transfusion-dependent patients with thalassemia major and chronic hepatitis C.

The purpose of this study was to determine whether interferon-alfa (IFN-alpha) therapy benefits patients with transfusion-dependent thalassemia and chronic active hepatitis C, and whether their iron burden modifies the response to this therapy. We conducted a controlled trial of recombinant IFN-alpha (3 million units per square meter of body surface area, three times a week for 15 months) in 65 patients with thalassaemia major and chronic active hepatitis C; 14 of them were untreated control subjects. In 21 of the 51 treated patients, alanine aminotransferase values returned to normal within 6 months, and hepatitis C virus ribonucleic acid was no longer detected in serum; no changes were detected among control subjects. The response to IFN-alpha therapy was inversely related (p < 0.002) to the liver iron burden as assessed by atomic absorption, the histologic semiquantitative method, or both methods. During 3 years of follow-up, two responder patients had relapses. We conclude that IFN-alpha represents a useful therapeutic option for children with transfusion-dependent thalassemia and chronic active hepatitis C with a mild to moderate iron burden.

A gene dosage effect of the DQA1*0501/DQB1*0201 allelic combination influences the clinical heterogeneity of celiac disease.

This study reports the HLA-DR and DQ molecular characterization of 62 CD patients of Sardinian descent. Patients were divided in two groups (36 in group I and 26 in group II) according to the clinical features at the disease onset. Among the patients of group I, having the fully expressed form of CD and a mean age of 3 years at disease onset, a significant increase of DRB1*0301, DQA1*0501, DQB1*0201 homozygotes, encoding in cis two DQ (alpha 1*0501, beta 1*0201) susceptibility heterodimers, was observed when compared either with the patients of group II (pIII < 0.012) or with healthy individuals (pI < 10(-6)). On the other hand, in the patients of group II, presenting oligosymptomatic forms and a mean age of 5.7 years at the disease onset, the haplotype combinations encoding in cis or in trans only one DQ (alpha 1*0501, beta 1*0201) heterodimer were significantly increased in comparison either with the patients of group I (pIII < 0.026) or with controls (pII < 10(-6)). These findings suggest that a double dose of DQA1*0501, DQB1*0201 genes may predispose a person to an earlier onset and to more severe disease manifestations. Genotype analysis showed that only three patients (all in group I) failed to form in trans or in cis the DQ (alpha 1*0501, beta 1*0201) heterodimer and carried the DQA1*0101,DQB1*0501 haplotype, suggesting its possible role in CD susceptibility. In addition, a significant increment of DQB1*0501 gene (pc < 0.0065) was found comparing the frequency of DQB1 alleles in CD patients and healthy controls, after exclusion of DQB1*0201 chromosomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of antibodies to hepatitis C virus in a long-term prospective study of posttransfusion hepatitis among thalassemic children: comparison between first- and second-generation assay.

During an 8-year prospective study of post-transfusion hepatitis conducted at the Thalassemic Center of Cagliari (Italy), including 135 newly diagnosed thalassemic children on long-term transfusion maintenance, 83 children (61%) developed non-A, non-B hepatitis (NANBH). Resolution of NANBH was observed in 17 (20%) cases, and chronicity in 57 (69%), whereas the remaining 9 (11%) experienced one or two additional bouts of acute NANBH. Of the 83 children with NANBH, 75 (90%) showed anti-hepatitis C virus (HCV) seroconversion when tested by second-generation enzyme-linked immunosorbent assay (ELISA), whereas first-generation ELISA showed anti-HCV in only 59 (71%) cases (p = 0.003). Moreover, the newly developed assay allowed an earlier detection of anti-HCV response in most of the patients who seroconverted by both assays, reducing significantly the mean onset-seroconversion interval (5 +/- 9.4 weeks vs. 14.5 +/- 20.8 weeks, p < 0.05). It was significantly more sensitive for the identification of HCV infection, not only in resolving NANBH, but also in NANBH progressing to chronicity (79 vs. 35%, respectively, p = 0.008; and 93 vs. 79%, p = 0.028). The pattern of antibody response with first-generation assay was characterized by clearance of anti-HCV with time, in most of the patients who recovered, and by persistence of anti-HCV in the majority of those who progressed to chronicity, whereas second-generation ELISA usually showed persistence of anti-HCV over time, regardless to the outcome of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)