Genotypic testing on HIV-1 DNA as a tool to assess HIV-1 co-receptor usage in clinical practice: results from the DIVA study group.

PURPOSE: We have developed a sequencing assay for determining the usage of the genotypic HIV-1 co-receptor using peripheral blood mononuclear cell (PBMC) DNA in virologically suppressed HIV-1 infected patients. Our specific aims were to (1) evaluate the efficiency of V3 sequences in B versus non-B subtypes, (2) compare the efficiency of V3 sequences and tropism prediction using whole blood and PBMCs for DNA extraction, (3) compare the efficiency of V3 sequences and tropism prediction using a single versus a triplicate round of amplification. RESULTS: The overall rate of successful V3 sequences ranged from 100 % in samples with >3,000 copies HIV-1 DNA/10(6) PBMCs to 60 % in samples with <100 copies total HIV-1 DNA /10(6) PBMCs. Analysis of 143 paired PBMCs and whole-blood samples showed successful V3 sequences rates of 77.6 % for PBMCs and 83.9 % for whole blood. These rates are in agreement with the tropism prediction obtained using the geno2pheno co-receptor algorithm, namely, 92.1 % with a false-positive rate (FPR) of 10 or 20 % and of 96.5 % with an FPR of 5.75 %. The agreement between tropism prediction values using single versus triplicate amplification was 98.2 % (56/57) of patients using an FPR of 20 % and 92.9 % (53/57) using an FPR of 10 or 5.75 %. For 63.0 % (36/57) of patients, the FPR obtained via the single amplification procedure was superimposable to all three FPRs obtained by triplicate amplification. CONCLUSIONS: Our results show the feasibility and consistency of genotypic testing on HIV-1 DNA tropism, supporting its possible use for selecting patients with suppressed plasma HIV-1 RNA as candidates for CCR5-antagonist treatment. The high agreement between tropism prediction by single and triple amplification does not support the use of triplicate amplification in clinical practice.

Bacterial skin and soft tissue infections: review of the epidemiology, microbiology, aetiopathogenesis and treatment: a collaboration between dermatologists and infectivologists.

Bacterial skin and soft tissues infections (SSTI) often determine acute disease and frequent emergency recovering, and they are one of the most common causes of infection among groups of different ages. Given the variable presentation of SSTI, a thorough assessment of their incidence and prevalence is difficult. The presence of patient-related (local or systemic) or environmental risk factors, along with the emergence of multi-drug resistant pathogens, can promote SSTI. These infections may present with a wide spectrum of clinical features and different severity, and can be classified according to various criteria. Many bacterial species can cause SSTI, but Gram-positive bacteria are the most frequently isolated, with a predominance of Staphylococcus aureus and Streptococcus pyogenes. The diagnosis of SSTI requires an extended clinical history, a thorough physical examination and a high index of suspicion. Early diagnosis is particularly important in complicated infections, which often require laboratory studies, diagnostic imaging and surgical exploration. SSTI management should conform to the epidemiology, the aetiology, the severity and the depth of the infection. Topical, oral or systemic antimicrobial therapy and drainage or debridement could be necessary, along with treatment of a significant underlying disease. This review discusses the epidemiology, the pathogenesis and the classification of bacterial SSTI, describes their associated risk factors and their clinical presentations. The authors provide a rational diagnostic and therapeutic approach to SSTI in respect of antibiotic resistance and currently available antimicrobial agents.

Syphilis with HIV in Florence, 2003-2009: a 7-year epidemiological study.

The aims of this study were to describe the trend of acquired syphilis in the city of Florence and its province over a 7-year period, to investigate sexual behaviours in the syphilis-infected population and to analyse syphilis/HIV co-infection. A total of 259 patients were classified according to age, sex and HIV infection. We estimated that from 2004 to 2008 cases increased by 248%. Most patients with concurrent HIV infection were male (31-45 years), but 40- to 60-year-old men who had sex with men predominated in both male and HIV-positive patients. Oral sex was identified as the most significant route of transmission, although most patients did not consider it so. Late-presenters with HIV accounted for 33% of HIV-positive patients: they were unaware of their HIV status and showed syphilis lesions only. In these cases, syphilis heralded the presence of HIV infection and allowed earlier diagnosis.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy.

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Use of patch testing for the diagnosis of abacavir-related hypersensitivity reaction in HIV patients.

BACKGROUND: The use of antiretroviral drug abacavir (ABC) has been often associated with cutaneous hypersensitivity reactions, the majority being severe. OBJECTIVE: The present study discusses the issues of patch testing associated with pharmacogenetic screening in light of the development of abacavir hypersensitivity reactions (HSRs). METHODS: The present authors classified 100 patients into three groups: 20 patients (group A) had experienced a hypersensitivity reaction when treated with highly active antiretroviral therapy (HAART) including ABC; 60 HIV-positive patients (group B) were receiving HAART scheme including ABC; 20 HIV-negative patients acted as control group (group C). Patients of group A and B were patch tested with ABC as such, then with an ABC extract diluted to 1 and 10% in petrolatum. Group C patients underwent patches with petrolatum only. A biopsy of the lesion was performed in those patients who showed a positive skin reaction. All patients had been tested for HLA-B5701. RESULTS: A correlation between positive ABC-patch testing and HLA-B5701 was found in 50% of patients enrolled in group A, while in group B and C, all patients tested negative for both genetic marker and ABC-patch testing. Histopathology findings confirmed a vigorous CD4+ and CD8+ cellular response that is compatible with HSR. CONCLUSIONS: Patch testing is a safe and sensitive method that can be used for to confirm or exclude any correlation between abacavir and hypersensitivity skin reactions in patients who have been previously treated with abacavir during HAART. Correlation between patch test, immunohistochimical, and genetic tests results shows that genetic testing increases the possibility to identify patients with a true reaction.

Case report: HIV infection from a kidney transplant.

The transmission of human immunodeficiency virus (HIV) through transplantation of human tissues and organs is rare but not impossible. A 27-year-old Bulgarian woman received a kidney transplant from a cadaveric donor owing to chronic renal failure due to glomerulonephritis of unknown etiology. Five days after the donation, the tissues showed HIV-1 infection, so she was immediately initiated on highly active antiretroviral therapy (HAART) with lopinavir/ritonavir, zidovudine, enfuvirtide, and lamivudine. Subsequently, according to the genotypic test which revealed a complex resistance pattern of the HIV-1, we changed the regimen to darunavir/ritonavir, etravirine, lamivudine, and enfuvirtide. The HIV-1 genome (550 UI/mL), which was detected at 5 days after transplantation, rapidly declined to undetectable levels at 3 weeks after HAART. The CD4+ T-cell nadir was 432 cells/microL (40%) to 1,400 cells/microL after 2 years. The posttransplantation course was complicated by cytomegalovirus pneumonia. At 32 months after transplantation, the patient had experienced hypertension with secondary retinopathy, bilateral cataracts, diabetes, hypothyroidism, osteoporosis with multiple vertebral fractures, a hip prosthesis, and a bone infarction of the femur. Major management problems had been related to steroid and HAART treatment side effects. Therapeutic interactions between the immunosuppressants and the antiretroviral drugs were complex for management, requiring frequent checks of drug levels and dose-adjustments. We finally obtained a stable clinical and viroimmunologic condition. The transmission of multiresistant strains of HIV from unknown patients requires complex multidisciplinary management.

Case report: cystic fibrosis, lung transplantation, and the novel H1N1 flu.

The H1N1 pandemic flu is a significant risk factor for both patients with chronic disease who need organ transplantation and transplant recipients. This population needs special care regarding comorbidities and related complications. MB, a 38-year-old Italian cystic fibrosis male patient with lung and pancreatic involvement, was referred to our division in July 2009 for fever-associated arthromyalgia, headache, and rhinitis. Lung transplantation had been performed in September 2005, and he was subsequently treated with immunosuppressive therapy: tacrolimus, everolimus, and prednisolone. In the past, chronic respiratory colonization with Pseudomonas aeruginosa and intermittent infection with Aspergillus flavus, chronic renal failure, hypertension, and diabetes mellitus complicated his clinical history. He started antiviral treatment with oseltamivir despite no travel history and no respiratory symptoms. H1N1 swab was positive. Three days later, the patient was admitted to the hospital for the persistence of fever and the onset of cough. Chest x-ray showed a left lower pneumonia, which was confirmed by computerized tomography. Broad-spectrum antibiotic therapy led to an improvement of the clinical condition. The patient was discharged 8 days later; a control swab was negative. This case report suggests some general considerations regarding solid organ recipients: 1) Flu-related complications require early treatment (both antiviral and antibiotic); 2) active microbiologic surveillance is important to prevent lethal infections (ie, invasive aspergillosis); 3) evaluation of immunosuppressant blood levels is necessary for drug-drug interactions. Active prevention is the best option for decreasing morbidity and mortality in the transplanted patient.

Italian guidelines for the diagnosis and infectious disease management of osteomyelitis and prosthetic joint infections in adults.

Bone and joint infections are recognized as difficult-to-treat infections that result in significant morbidity and mortality among patients and increased healthcare costs. This article presents the recommendations for the diagnosis and management of osteomyelitis and prosthetic joint infections in adults developed by Bone and Joint Infections Committee for the Italian Society of Infectious and Tropical Diseases. It contains data published through to November 2007. An evidence-based scoring system that is used by the Infectious Diseases Society of America was applied to treatment recommendations.

Disseminated Scedosporium apiospermum infection in renal transplant recipient: long-term successful treatment with voriconazole: a case report.

Scedosporium apiospermum, the asexual form of Pseudallescheria boydii, is a ubiquitous fungus that represents an unfrequent complication of immune suppression. It accounts for 20% of all non-Aspergillus mold infections in organ transplant recipients. The infection can be localized or disseminated in multiple organs, including lungs, brain, joints, tendons, and skin, and is difficult to treat, due to resistance of S apiospermum to amphotericin B and other antifungal agents. The mortality rate is about 50%. To our knowledge, there are no prospective studies or registries of transplant recipients to guide diagnosis and there are no evidence-based recommendations for the optimal management of this infection. We report a case of S apiospermum infection in a woman with renal transplantation. The first occurrence of infection was a solitary nodule on the forearm, which was surgically excised. Two following relapses were disseminated to the knee, the Achilles tendon, and the skin of the left leg. The infection was successfully treated with voriconazole, but due to the severe iatrogenic immune suppression, a strong reduction in immunosuppressant drugs was needed.

[Bacterial meningitis in adults: a retrospective multicentric study in Tuscany (Italy)]. / Le meningiti batteriche dell'adulto: studio retrospettivo multicentrico della Toscana.

The Infectious Diseases Unit of Lucca Hospital conducted a multicentric retrospective study to evaluate the epidemiological and clinical features of adult patients affected by bacterial meningitis attending all the Infectious Diseases Units of Tuscany (Italy) from July 1999 to June 2004. A specific questionnaire was sent to all the units to collect information about each case of bacterial meningitis occurring in patients older than sixteen. Patients with meningitis by Mycobacterium tuberculosis were excluded from the analysis. Nine out of 12 Infectious Diseases Units of Tuscany took part in the study and 197 cases were identified. Most cases of meningitis occurred during 2002 with a slight reduction in cases in subsequent years. Streptococcus pneumoniae and Neisseria meningitidis were the most frequently isolated pathogens with an increase in diagnosis from 1999 to 2004; in 23.8% of patients no pathogens were isolated, with a reduction in meningitis from unknown aetiology from 1999 to 2004. Most patients were treated with a combination of two antibiotics, and corticosteroid drugs were added to the therapy; in the group of patients treated with corticosteroid drugs invalidating complications occurred in 23% of cases and 5% of patients died. In all, 27 out of 197 subjects (13.7%) developed invalidating complications and 20 out of 197 patients (10.2%) died.

First case of Mycobacterium haemophilum infection in an AIDS patient in Italy.

Mycobacterium haemophilum, a strongly acid- and alcohol-fast bacillus belonging to the group of non-tuberculous mycobacteria was first described in 1978 as the cause of cutaneous ulcerating lesions in a woman with Hodgkin's disease. Infection due to M. haemophilum is rare but increasing in prevalence in immnunosuppressed subjects, particularly in patients with acquired immunodeficiency syndrome (AIDS) patients. The skin is the most common site of infection with erythematous or violaceous papules and/or nodules that are usually painless at first, but some elements develop into abscesses or ulcers that can become very painful. The incidence of M. haemophilum is unknown, but cases of infection have been reported in Australia, Canada, the United States, France, Israel, the United Kingdom and Taiwan; to date no cases have been reported in Italy, thus the case reported here is apparently the first one observed in our country.

Evaluation of a rapid immunochromatographic test for the serologic diagnosis of tuberculosis in Italy.

OBJECTIVE: To determine specificity, sensitivity and predictive values of a rapid immunochromatographic assay (ICT tuberculosis) for the diagnosis of tuberculosis (TB) in an Italian clinical setting, and to identify tentative new guidance for the interpretation of test results. METHODS: The ICT tuberculosis test is an immunochromatographic test based on the detection of IgG antibodies directed against five highly purified antigens secreted by Mycobacterium tuberculosis during active growth. Sera from 60 patients with active pulmonary (48 sputum smear-positive and six sputum smear-negative cases) and extrapulmonary (six cases) TB were obtained. Personal, anamnestic and clinical data were investigated and recorded for each patient. The control groups comprised 156 subjects: 40 healthy individuals, half of them Mycobacterium bovis BCG-vaccinated, and 116 patients with mycobacterial diseases other than TB (five cases), with nonmycobacterial lung diseases (30 cases), with nonmycobacterial nonlung diseases (30 cases), with nonmycobacterial diseases and rheumatoid factors positivity (30 cases), and with asymptomatic HIV infection (21 cases). For 21 individuals the test was simultaneously performed with both serum and whole blood sample. Each positive result of the ICT test was reported with regard to the number (1-4), position (A, B, C, D) and color intensity (+ to ++++) of the evidenced lines in order to assess the quality of the antibody response. RESULTS: The overall sensitivity and specificity were 56.7% and 90.4%, respectively. The sensitivity for pulmonary TB patients was 61.1% (66.7% for smear-positive and 16.7% for smear-negative cases) and 16.7% for extrapulmonary TB patients. The difference between ICT results in pulmonary TB patients and control subjects was statistically significant (P < 0.0001). The analysis of the positive ICT tests revealed that samples with strong color intensity (>/=++) and specific antibodies bound to antigens immobilized on line D were significantly more frequent in TB patients than in controls (P = 0.001 and P= 0.027, respectively). ICT test results with the presence of at least three visible lines were more often observed in the TB patients than in controls, although not reaching statistical significance (P = 0.052). No difference was observed between the results of the ICT test performed both on serum and whole blood sample. CONCLUSIONS: The ICT tuberculosis test was confirmed to be rapid and easy to perform without requiring special equipment, both on serum and whole blood sample. Our data, in accordance with those obtained in a previous study conducted in extra-European countries, confirmed higher sensitivities for the smear-positive TB patients than for the smear-negative TB patients, and for pulmonary TB patients than for the extrapulmonary TB patients. Data obtained on the quality of antibody response in the ICT positive samples, might be used to improve the performance of the test.

Reverse transcriptase mutations in HIV-1 infected patients treated with two nucleoside analogues: the SMART study.

Resistance to nucleoside reverse transcriptase inhibitors (NRTIs) was studied in 527 HIV-1-infected patients, 342 responder and 185 non-responder to two NRTIs. Responders were followed for one year to assess the incidence of clinical failure. The prevalence of the 215Y/F substitution was higher among non-responder, compared to responder patients (33.7&#x0025 vs. 17&#x0025, P = 0.0005), whereas the prevalence of the 184V and of the 70R mutations was comparable between these two groups. The 74V substitution was never observed and the 75T mutation was detected in only two subjects non-responder to a stavudine including regimen. Reduced susceptibility to didanosine or stavudine was infrequent. Reduced susceptibility to zidovudine was observed in 25&#x0025 of individuals failing a zidovudine including regimen, whereas reduced susceptibility to lamivudine was detected in all subjects failing a lamivudine including regimen. In the prospective analysis, patients with undetectable viral load at enrollment had a lower incidence of failure rate over one year compared to those with detectable HIV-RNA at entry (P &#x003C 0.0001). A detectable viral load at enrollment was the only independent variable that predicted clinical failure over one year (P &#x003C 0.0001).

Plasma viral load concentrations in women and men from different exposure categories and with known duration of HIV infection. I.CO.N.A. Study Group.

CONTEXT: According to recent studies, women have lower plasma HIV RNA concentrations than men. However, these studies did not take into account the duration of HIV infection. OBJECTIVES: To analyze the relationship between viral load and gender among individuals with known date of seroconversion. SETTING: Sixty infectious disease clinics in Italy. DESIGN: Cross-sectional analysis of data collected at enrollment in a cohort study. PARTICIPANTS: Injecting drug users and heterosexual contacts naive to antiretroviral therapy at enrollment (245 men; 170 women). MAIN OUTCOME MEASURES: Plasma HIV RNA concentrations, measured using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) or signal amplification b-DNA assays before antiretroviral therapy. RESULTS: Plasma HIV RNA concentrations were similar by age and exposure category (p =.80 and p =.39, respectively). Median viral load among women was roughly half that of men (p =.002). The association between viral load and gender remained significant after fitting a two-way analysis of variance (p =.03) and after adjusting for CD4 count, modality of HIV transmission, and age at enrollment in a regression model. Viral load was 0.27 log10 copies/ml (95% confidence interval, 0.05-0.40; p =.01) lower in women (i.e., 50% lower in the raw scale). CONCLUSIONS: Plasma HIV RNA concentrations were found to be lower among women, even when considering the duration of HIV infection. Compared with men, it is possible women should be given highly aggressive antiretroviral therapy at lower HIV-RNA concentrations.

Blood viscosity and red cell morphology in subjects suffering from cirrhosis before and after treatment with S-adenosyl-L-methionine (SAM).

Alterations of fluidity of the hepatocytic membrane and of the transport related systems are the basis of the cholesteatic syndrome and favour the tissue accumulation of cytotoxic metabolites. S-Adenosyl-L-Methionine (SAM) is a natural molecule which acts as a giver of methylic groups and as an enzymatic activator in several enzymatic actions of transmethylase and of transulphuration and plays a key role in biochemical processes of hepatic cell. The aim of our study was to evaluate the effects of SAM on the restoration of the membrane fluidity and on the hepatic function in general. In studying the fluidity of the cell membrane we evaluated some hemorheological parameters (total blood viscosity and red cell morphology). Fluidity of the red cell membrane is one of the most important elements of red cell rheology. We studied 15 patients (Group A) suffering from micro- and macro-nodular cirrhosis verified through hepatic biopsy, with alcoholic or post-viral causes. We evaluated the values of: blood viscosity (with a cone-plate rheometer by Carri-med), haematocrit, plasma fibrinogen and the erythrocytic morphology at the optical microscope with the Zipursky-Forconi method before and after 7 days of therapy with SAM i.v.. Data were compared with those of a similar group (Group B) treated with traditional therapy only (hyposodic and hypoprotein diet supplemented with multivitamin preparations, vitamin K in particular, if necessary, and potassium sparing diuretics). We also measured biliary salts, alkaline phosphatase, transaminase and gamma-GT. In the first group we observed a statistically significant reduction of blood viscosity, haematocrit didn't change significantly; biliary salts reduced in a statistically significant way. Evaluation of red cell morphology showed in all cases a pathological percentage (>15%) of echinocytes and knizocytes which reduced to a mean of 5% after SAM therapy. We observed no further modifications of the other hemorheological parameters. Results demonstrate that SAM has a positive action on the fluidity of the membrane, as indicated by the improvement of haemorheological parameters and by the significant decrease of biliary salts, indicating the presence of cholesteasis.

Strongyloides stercoralis: ultrastructural study of newly hatched larvae within human duodenal mucosa.

AIM: To investigate the ultrastructural features of the newly hatched larvae of Strongyloides stercoralis in human duodenal mucosa. METHODS: Duodenal biopsies from an AIDS patient were studied by transmission electron microscopy to investigate morphology, location, and host-worm relations of newly hatched larvae. RESULTS: Newly hatched larvae were found in the Lieberkuhn crypts within the tunnels formed by migration of parthenogenic females. Delimiting enterocytes were compressed. Release of larvae into the gut lumen was also documented. It was shown that both a thin and a thick membrane surrounded the eggs and larvae, as a tegument derived respectively from parasite and host. Segmentary spike-like waves, caused by contractures of worm body musculature, were observed on the surface of newly hatched larvae, and their intestinal lumen was closed and empty, with no budding microvilli. Immaturity of the cuticle and some degree immaturity of amphidial neurones were found, but there was no evidence of either immaturity or signs of damage to other structures. CONCLUSIONS: Newly hatched larvae of S stercoralis appear to be a non-feeding immature stage capable of active movement through the epithelium, causing mechanical damage. The tegument resulting from the thin and the thick membrane may protect the parasite and reduce any disadvantage caused by immaturity.