The diabetes-tuberculosis co-epidemic: the role of international migration.

SETTING: A tuberculosis (TB) referral centre in Rome, Italy. OBJECTIVE: To identify demographic and epidemiological characteristics associated with diabetes mellitus (DM) among patients with TB and to compare the clinical presentation of TB and TB-DM in the light of the growing worldwide burden of DM. DESIGN: We performed a retrospective study of TB cases diagnosed from 2007 to 2012. RESULTS: Among 971 TB patients, 723 were foreign-born and 63 (6.5%) had DM. DM prevalence was 12.7% (8/63) among those born in countries with DM prevalence ⩾8%, 4.7% (31/660) among patients from countries with DM prevalence <8% and 9.7% among Italian patients (24/248). In multivariable analysis, DM was independently associated with older age, and with being born in countries other than Italy, compared to Italians; this latter association was stronger in older patients. DM patients were also significantly more likely to be male and less likely to test positive for the human immunodeficiency virus. The presence of cavities was significantly associated with DM. CONCLUSIONS: As individuals born in high TB incidence and high DM prevalence countries emerge as a vulnerable population, greater attention to bidirectional low-cost screening in people from these countries is needed.

A case of Alkhumra virus infection.

Alkhumra virus (ALKV) is an emerging tick-borne flavivirus known to cause a neglected tropical disease in the Middle East. The magnitude of the disease among European returning travelers is still unknown probably because the inadequate knowledge about the real geographic distribution of ALKV infection have limited its diagnosis. Up to now in Italy were reported only three cases; here we report the fourth case of ALKV in a returning traveler from south Egypt.

Fulminant VZV infection in an adult AIDS patient treated with steroids: a case report.

Varicella zoster virus (VZV) typically causes a benign disease in childhood. However, VZV can lead to severe complication in immunocompromised patients, involving skin and nearly every organ system, with significant morbidity and mortality. VZV infection occurs more frequently in patients treated with steroids. Herein, we describe a case of rapidly fatal disseminated VZV infection with cutaneous and visceral involvement in an adult AIDS patient treated with steroids.

Combined rehabilitation program for postural instability in progressive supranuclear palsy.

BACKGROUND: Progressive supranuclear palsy (PSP) is an atypical parkinsonism clinically characterized by prominent axial extrapyramidal motor symptoms with frequent falls. The clinical response to L-dopa is poor and there is strong need for alternative treatment strategies. METHODS: We tested the efficacy of a rehabilitative program combining a dynamic antigravity postural system (SPAD) and a vibration sound system (ViSS) on postural instability of 10 patients affected by PSP. The patients underwent SPAD and VISS treatments with a 3 sessions/week schedule for 2 months. Patients were clinically examined at baseline, every week during the 2-months treatment, and at 1 month after the end of treatment for the following parameters: baropodometry static, baropodometry dynamic and stabilometry. PSP rating scale and PD36 quality of life scale were also administered. RESULTS: The combined rehabilitative program produced improvement of all the parameters explored (p = 0.01-0.05) at the end of treatment as compared to baseline. Baropodometric dynamics improvement lasted until the end of follow-up. CONCLUSION: Our results suggest that a specific rehabilitation program could improve postural instability in PSP patients. A more continuous treatment protocol would allow stabilizations of results.

An adult HIV patient with unilateral Moyamoya syndrome.

Moyamoya disease is a rare idiopathic neurological disorder due to occlusion of the circle of Willis. "Moyamoya syndrome", a radiographic picture resembling Moyamoya disease, is associated with systemic diseases. Only two cases of moyamoya syndrome in adults with advanced HIV disease and a single case in a child have been reported until now. We describe a case of unilateral Moyamoya syndrome in a patient with well-controlled HIV infection.

[Dialysis and quality of life: identifying and managing critical aspects]. / Terapia dialitica e qualitá di vita: individuare le aree di criticitá per orientare alla metodica più idonea.

Living with a chronic disease is for the patient a ''disease experience'' that also affects the psychosocial sphere and has a negative impact on perceived quality of life. To estimate the effect of dialysis on the perceived quality of life and to identify by means of a specific questionnaire the aspects that are compromised most. From our results it emerged that the examined patients had a sufficiently good total perception of quality of life, even though about 30% of the patients reported critical aspects related to daily life and, in some age groups, also related to dialysis method. This study confirms the importance of developing educational and supportive predialysis programs in order to identify and reduce the critical aspects.

HIV infection among low-risk first lifetime testers in Rome, 1990-2000.

BACKGROUND: HIV spread among low-risk populations through heterosexual intercourse is a major public health concern. This study was aimed at describing prevalence and determinants of HIV infection among Italian low-risk subjects seeking their first lifetime HIV test. PATIENTS AND METHODS: Information collected between January 1990 and December 2000 at a major counseling and testing site in Rome, Italy, was analyzed. Multiple logistic regression odds ratios (OR) and 95% confidence intervals (CI) were computed. RESULTS: Among the 14,313 study subjects, 64 (0.4%) were seropositive for HIV infection. HIV seropositivity increased with age (OR = 4.0, 95% CI: 2.1-7.6 for >/= 40 years vs 18-24), and it seemed to be more common among men (OR = 1.6, lower 95% CI:0.9). There was no evidence of temporal variations, whereas motivations for HIV testing were strongly associated with HIV prevalence. Testing for alarming symptoms (OR = 13.8) or for heterosexual intercourse (OR = 11.0) were associated with a more than 10-fold increased HIV risk. CONCLUSION: Our findings are consistent with data from other industrialized countries and they show a strong association between HIV seropositivity and reason for first-time testing. Moreover, they indicate a stable trend of HIV prevalence among low-risk persons in the last decade. Further studies on time trends in low-risk populations would be useful to evaluate current HIV prevention programs.

Changes in host cell molecules acquired by circulating HIV-1 in patients treated with highly active antiretroviral therapy and interleukin-2.

OBJECTIVE: To analyse cell membrane proteins (CMP) acquired by HIV-1 present in the plasma of asymptomatic patients, and their modifications after a cycle of highly active antiretroviral therapy (HAART) and interleukin (IL)-2. DESIGN AND METHODS: Plasma samples from eight drug-naive asymptomatic subjects underwent immobilized antibody capture (IAC) to detect CMP on the surface of circulating HIV-1. The CMP considered were lymphocyte subset markers (CD45RA, CD45RO), activation markers (HLA-DR), adhesion molecules (LFA-3), costimulatory proteins (B7-2), lymph-node homing receptors (CD62L) and pro-apoptosis molecules (FasL). This analysis was repeated after one cycle of HAART + IL-2, after virus rebound. RESULTS: LFA-3, followed by CD45RO and HLA-DR, are the most represented CMP on the surface of circulating virions in naive asymptomatic patients; CD45RA, CD62L, B7-2 and FasL are detected only occasionally. After rebound, a significant reduction of CD45RO and HLA-DR, but not of LFA-3, is observed on virions, whereas CD45RA and CD62L, as well as other molecules, are not affected, remaining almost undetectable. CONCLUSIONS: Assuming that CMP on HIV-1 reflect the cellular origin of virions, activated T cells expressing CD45RO, HLA-DR, and LFA-3 may be the main source of HIV-1 in asymptomatic patients. After a cycle of HAART + IL-2, followed by therapy interruption, CD45RA and CD62L are detected on virions rarely, indicating that even during virus rebound, expanded naive T cells do not become a major target of virus replication. Furthermore, the presence of HLA-DR on rebound HIV-1 is decreased, consistent with decreased activation of the HIV-producing cells. More extensive investigation may clarify the significance of these findings with respect to pathogenesis.

Decay of HIV type 1 DNA and development of drug-resistant mutants in patients with primary HIV type 1 infection receiving highly active antiretroviral therapy.

The present study was aimed at describing the effect of highly active antiretroviral therapy (HAART) in 10 patients with primary HIV infection (PHI). Clearance rates of HIV RNA and HIV DNA in peripheral blood as well as the preexistence and the emergence of drug-resistant strains of HIV were determined over 52 weeks of treatment. The data indicate that HAART is able to induce a suppression of plasma viral load together with a significant decrease, but not a suppression, of peripheral blood mononuclear cell-associated proviral DNA in PHI subjects. Analysis of drug-resistant strains revealed that three PHI patients, showing a complete virologic response, developed mutations in the pol gene, thus suggesting that a persistent residual virus replication exists despite a sustained suppression of plasma viremia.

The changing picture of the HIV/AIDS epidemic.

Twenty years after it was first recognized, the HIV/AIDS epidemic continues to expand, but its impact varies greatly in different parts of the World. The worst of the epidemic is now centered in developing countries, especially sub-Saharan Africa, and areas such as Eastern Europe, which was only marginally involved a few years ago but has recently experienced the largest growth in the epidemic. In industrialized countries Highly Active Antiretroviral Therapy (HAART) has changed the natural history of HIV/AIDS, causing a reduction in mortality and morbidity due to HIV/AIDS and related diseases. Many interlocking factors determine the impact of HAART at the population level, including reduction of morbidity and mortality, changes in the natural history of HIV/AIDS and associated illnesses, and the effects of HAART on HIV transmission. To fully appreciate the potential benefits of HAART, the epidemic should continue to be monitored in the future, and the effects of HAART on reducing HIV transmission should also be evaluated. Interventions addressed to encourage the adoption of safer sex practices are badly needed, since a "rebound" in risky sexual behaviors was recently reported among high risk groups, which is, at least in part, attributable to the optimism about new treatments.

Metabolic and morphologic disorders in patients treated with highly active antiretroviral therapy since primary HIV infection.

UNLABELLED: Our objective was to describe morphologic and metabolic disorders in patients treated with highly active antiretroviral therapy (HAART) since primary HIV infection (PHI). Our method was prospective evaluation of patients with PHI initiating HAART at the time of diagnosis. Outcome measures were: development of hyperglycemia, hypercholesterolemia, hypertriglyceridemia, and of body shape abnormalities indicative of lipodystrophy, assessed through self-reported questionnaires and physical examination. RESULTS: From May 1997 to April 2001, 41 patients (35 males) with PHI presented at the National Institute for Infectious Diseases "Lazzaro Spallanzani" in Rome, Italy. A protease inhibitor-including regimen was started in 30 patients, and a nonnucleoside reverse transcriptase-inhibitor in 11. Median interval between enrollment and treatment initiation was 30 days (mean 39, range 10-150). Median HAART duration was 19 months (mean 21.2, range 3-47). Thirty-eight patients had undetectable (less than 80 cp/mL) HIV RNA after a median of 3 months (mean 4.1, range 1-15). Mean CD4 cells count increased from 632/mmc at baseline to 936/mmc at the last follow up. No cases of hyperglycemia (glucose level greater than 110 mg/dL) were observed. After a median of 6 months on HAART, 10 patients developed beyond grade 2 (greater than 240 mg/dL) hypercholesterolemia, 5 developed beyond grade 2 (greater than 400 mg/dL) hypertrygliceridemia, and two developed both. Body mass index did not change significantly. Five patients (12.2%) developed lipodystrophy after a median of 14.5 months (mean 15.3, range 2-30), with an incidence of 7.3 per 100 patient-years. CONCLUSIONS: Dyslipidemia and lipodystrophy can occur in patients treated with HAART since PHI. This risk of should be taken into account when considering this early antiretroviral treatment of HIV infection.

Cloning and functional analysis of sucrose:sucrose 1-fructosyltransferase from tall fescue.

Enzymes of grasses involved in fructan synthesis are of interest since they play a major role in assimilate partitioning and allocation, for instance in the leaf growth zone. Several fructosyltransferases from tall fescue (Festuca arundinacea) have previously been purified (Lüscher and Nelson, 1995). It is surprising that all of these enzyme preparations appeared to act both as sucrose (Suc):Suc 1-fructosyl transferases (1-SST) and as fructan:fructan 6(G)-fructosyl transferases. Here we report the cloning of a cDNA corresponding to the predominant protein in one of the fructosyl transferase preparations, its transient expression in tobacco protoplasts, and its functional analysis in the methylotrophic yeast, Pichia pastoris. When the cDNA was transiently expressed in tobacco protoplasts, the corresponding enzyme preparations produced 1-kestose from Suc, showing that the cDNA encodes a 1-SST. When the cDNA was expressed in P. pastoris, the recombinant protein had all the properties of known 1-SSTs, namely 1-kestose production, moderate nystose production, lack of 6-kestose production, and fructan exohydrolase activity with 1-kestose as the substrate. The physical properties were similar to those of the previously purified enzyme, except for its apparent lack of fructan:fructan 6(G)-fructosyl transferase activity. The expression pattern of the corresponding mRNA was studied in different zones of the growing leaves, and it was shown that transcript levels matched the 1-SST activity and fructan content.

Decreased CD95 expression on naive T cells from HIV-infected persons undergoing highly active anti-retroviral therapy (HAART) and the influence of IL-2 low dose administration. Irhan Study Group.

The functional recovery of the immune system in HIV-infected persons receiving HAART and the role of adjuvant immune therapy are still matters of intensive investigation. We analysed the effects of HAART combined with cytokines in 22 naive asymptomatic individuals, randomized to receive HAART (n = 6), HAART plus a low dose (1000 000 U/daily) of rIL-2 (n = 8), and HAART plus rIL-2 after previous administration of granulocyte colony-stimulating factor (n = 8). After 3 months of therapy, increased CD4+ T cell counts and diminished viral loads were observed in all patients, independently of cytokine addition. A decreased expression of CD95 (Apo 1/Fas) was evident in all groups when compared with values before therapy. The percentages of peripheral blood mononuclear cells (PBMC) expressing CD95 after therapy decreased by 15%, 22% and 18% in the three treatment groups, respectively (P < 0.05). Analysis of PBMC subsets demonstrated that CD95 expression was significantly reduced on CD45RA+CD62L+ naive T cells (25.3%, 22.4%, and 18.6%, respectively; P < 0.05) in each group, after therapy. Accordingly, all patients showed a reduced rate of in vitro spontaneous apoptosis (P < 0.05). Another effect induced by HAART was a significant increase in IL-2Ralpha expression on total PBMC (P < 0.05), independently of cytokine addition. Altogether, our results suggest that very low dose administration of rIL-2 (1000 000 U/daily) may be not enough to induce a significant improvement in the immune system as regards HAART alone. The employment of higher doses of recombinant cytokines and/or different administration protocols in clinical trials might however contribute to ameliorate the immune reconstitution in patients undergoing HAART.

Low-dose IL-2 reduces lymphocyte apoptosis and increases naive CD4 cells in HIV-1 patients treated with HAART.

During HIV disease an increased in vitro apoptosis of peripheral blood mononuclear cells has been demonstrated. This can be reversed in vitro by interleukin (IL)-2. Recent trials with highly active antiretroviral therapy (HAART) and IL-2 in HIV-1-infected patients showed promising immunological and clinical results. Here we investigated the effects of subcutaneous low-dose IL-2 administration in combination with HAART on in vitro apoptosis and the relationship between apoptosis, CD4(+) counts, and HIV replication. Twenty-two asymptomatic HIV patients were randomized for HAART (arm I) and HAART plus IL-2 (arm II). Spontaneous apoptosis was decreased in both arms after 28 weeks of therapy but the reduction was highly significant only in arm II (P = 0.05 vs P = 0.001). As the percentage of apoptosis decreased, there was a significantly higher increase of both CD4(+) and CD4(+) naive T cells in arm II vs arm I. HIV plasma viremia was reduced in all patients after therapy. Our data suggest that intermittent therapy with low-dose subcutaneous IL-2 in addition to HAART induces a positive immunomodulation in asymptomatic HIV-infected patients.

Primary effusion lymphoma containing human herpesvirus 8 DNA in two AIDS patients with Kaposi's sarcoma.

BACKGROUND AND OBJECTIVE: Primary effusion lymphomas (PELs) containing Kaposi's sarcoma-associated herpesvirus (human herpesvirus 8/HHV-8) DNA sequences represent a distinct but heterogeneous group of rare non-Hodgkin's lymphomas of null-cell phenotype/B-cell origin. We aimed to describe the clinicopathologic features of two human immunodeficiency virus (HIV)-related PELs occurring in homosexual men with Kaposi's sarcoma (KS). DESIGN AND METHODS: Thoracentesis was followed by morphologic plus immunophenotypic studies and molecular analysis of tumor cell DNA by means of combination of polymerase chain reaction and Southern blot analysis. RESULTS: Patients developed recurrent lymphomatous effusions lacking tissue involvement, in the context of severe immunodepression (CD4 count < 60/microL) and anti-retroviral therapy. The effusions disclosed an immunoblast-like population CD45/CD30+, but B-cell- and T-cell-associated antigen negative, showing clonal immunoglobulin heavy chain gene rearrangements and harbouring HHV-8 DNA sequences. One case contained Epstein-Barr virus genome with no evidence of c-myc, bcl-2 and bcl-6 gene alterations. Both patients had aggressive disease. INTERPRETATIONS AND CONCLUSIONS: These cases represent additional examples of PEL associated with HHV-8 and confirm that the group of HIV-positive homosexual men may be at highest risk for PEL.

[Cytomegalovirus infection in HIV]. / Il citomegalovirus nell'infezione da HIV.

The data are taken from a retrospective study of 24 patients with AIDS who developed CMV disease. This study was performed to detect the principal characteristics associated with the development of CMV disease. Age, sex, risk factors, the time interval between HIV seropositivity to CMV disease were examined, as well as efficacy of gancyclovir therapy in both groups of patients with symptomatic and asymptomatic retinitis. When the chorioretinitis is still asymptomatic the early treatment of CMV disease may suppress progression of retinic lesions and seems to be efficacious to prevent the evolution of CMV disease.

Massive intrabronchial aspiration of contents of pulmonary abscess after fiberoptic bronchoscopy.

A patient with a putrid pulmonary abscess that did not resolve developed massive aspiration of the contents of the cavity following a fiberoptic bronchoscopic procedure. Precautions for before and after a bronchoscopic procedure are suggested to prevent this catastrophic complication in patients with pulmonary abscesses.

M-mode ultrasonic localization of pleural effusion. Use in patients with nondiagnostic physical and roentgenographic examinations.

Fifty patients had nondiagnostic physical and roentgenographic examinations and were believed at high risk for exploratory thoracentesis. Negative echograms for pleural fluid were recorded for 13 patients. For 34 patients, the characteristic M-mode display of a central echo-free space, indicative of pleural fluid, was recorded. Aspiration yielded fluid that was localized by echography in 30 (88%). Of the 30 patients, 13 (43%) had normal lateral decubitus views, and 10 (33%) had experienced unsuccessful aspiration before ultrasound localized the fluid loculation. The remaining seven patients, including three receiving mechanical ventilation who were believed to have increased risk for thoracentesis had successful initial tap based on echographic localization of fluid. Ultrasound allows detection and localization of pleural fluid when roentgenographic and physical diagnostic means are not helpful.