Volume 16, Issue 4, 2008
Review
Tuberculosis-associated immune reconstitution inflammatory syndrome
Leone Sebastiano,
Nicastri Emanuele,
Giglio Sergio,
Corpolongo Angela,
Narciso Pasquale,
Acone Nicola
The prognosis of HIV-infected patients has dramatically improved since the advent of HAART. The immune recovery associated with HAART may result in immuno-pathological reactions and clinical deterioration when HAART is initiated in patients with tuberculosis (TB). This phenomenon is defined as immune reconstitution inflammatory syndrome (IRIS). In this review, we summarise the epidemiology, clinical presentations and management of TB-associated IRIS.
Informed consent to perform the HIV diagnostic test: how to behave when minors are involved
Prestileo Tullio,
Argo Antonina,
Triolo Valentina,
Zerbo Stefania,
Procaccianti Paolo
AIDS is a clinical picture related to Human Immunodeficiency Virus (HIV) infection. In the last 20 years this infection has spread progressively, with approximately 2.4 million children under 15 years old now infected. The HIV antibody test is generally used to reveal the infection. In most European countries the test is voluntary; in Italy, implementation of the test is now regulated by Law 135/90. Art. 5 of the law states that the test is voluntary while informed consent is obligatory. However, nothing is stated concerning the child’s consent. By contrast, other Italian laws (e.g., Law 194/78, Law 194/96 and DPR 309/90) establish that the physician should only accept the wishes of minors after first appraising the maturity of the child and his/her age. Physicians must inform the minor about testing risks, about the meaning of its result, and about the most important aspects of sexual education.. They may then decide to inform the parents if they feel that the child would be unable to take future decisions in the event of a positive HIV antibody test.
Original article
Aetiology of prosthetic joint infections in a tertiary care centre in Italy
Carrega Giuliana,
Bartolacci Valentina,
Burastero Giorgio,
Casalino-Finocchio Giorgetta,
Grappiolo Guido,
Salomone Carlo,
Sandrone Clemente,
Santoriello Luisa,
Riccio. Giovanni
Prosthetic joint infections (PJIs) represent a severe complication in orthopaedics. Coagulase-negative staphylococci (CoNS) and Staphylococcus aureus represent the most frequent cause, but Gram-negatives have also been reported. With a view to describing the aetiology of PJIs diagnosed from January 2005 to September 2007 at S. Corona Hospital in Pietra Ligure, Italy, we conducted
retrospective analysis of pathogens isolated from PJIs by means of surgical specimens, needle aspirates or swabs of fistula (3 samples). During the study period 228 PJIs were described and 141 (62%) were microbiologically documented and evaluated. Early and delayed infections represented 45% of episodes, while late infections were observed in 55%. The aetiology was monomicrobial in 84% of cases, and polymicrobial in 16%. CoNS and S. aureus were the most frequently isolated pathogens. In early and delayed infections methicillin resistant CoNS were 30% and 24%, respectively, while in late infections they were 17%. Methicillin-resistant S. aureus was isolated in 13% of early, 22% of delayed and 15% of late infections. Gram-negatives were described in 16% of episodes without differences being found in the three groups. In our report staphylococci represented the most frequent cause of PJIs. Methicillin-resistant strains were more frequently isolated in early and delayed infections, but their frequency in late episodes was not negligible. Polymicrobial infections and Gram-negative infections were also frequent.
Bronchoalveolar lavage as a diagnostic tool in patients with haematological malignancies and pneumonia
Cordani Stefano,
Manna Annunziata,
Vignali Monica,
Tascini Carlo
We report our experience concerning bronchoalveolar lavage (BAL) in adult patients affected by haematological malignancies. BAL was performed in patients with documented pulmonary diseases not responding to empirical antibiotic and antifungal therapies. Overall, 25 bronchoscopies were performed in 24 patients. This technique led to pathogen identification in 11 out of 24 patients (45%). In particular, we identified four cases of tuberculosis, four of aspergillosis, two of pneumocystosis, two bacterial pneumonia and one pneumonia sustained by CMV (in two cases, pneumonia was polymicrobial). In three cases, where microbiological diagnosis had been obtained by means of other exams (blood culture, urinary antigens), BAL negativity allowed us to exclude alternative diagnoses. Pulmonary location of haematological disease was diagnosed in seven patients. BAL drove a switch therapy in 54% of patients. When performed by expert operators, BAL is useful and safe also in frail patients, such as those affected by onco-haematological malignancies.
Off-label antibiotic use: malpractice or good clinical practice?
Lazzarini Luca,
Fabris Paolo,
Tramarin Andrea,
Conforto Mario Umberto,
Nicolin Roberto,
Giordani Maria Teresa,
Benedetti Paolo,
Manfrin Vinicio,
Pellizzer Giampietro
In Italy, off-label drug use has been forbidden since 1998. However, Italian law allows off-label treatment for single cases only if treatment is considered irreplaceable, and completely under physician responsibility. To assess the consequences of such regulations for the infectious diseases specialist, we listed the indications of intravenous and oral antibiotics available in our hospital pharmacy service, and discussed them in a pool of nine infectious diseases specialists. Indications were compared with the recommended treatment of major bacterial syndromes as suggested by the major guidelines and textbooks. We found that standard treatment for several bacterial infections is off-label. The pool of specialists concluded that some off-label use of antibiotics is vital to daily practice in infectious diseases. Scientific societies should promote guidelines as the standard reference for good clinical practice, which should not be based only on the respect of drug labels.
Prospective observational study of pneumonia in an Italian hospital
Sacchetti Rossella,
Aporti Manuela,
Bianco Lauretta,
Lazzari Claudio,
Legnani Pier Paolo,
Zanetti Franca,
Finzi Gian Franco,
Leoni Erica
A prospective observational study was conducted during a two-year period to evaluate the prevalence of hospitalized pneumonia in six hospital units of the Bologna S.Orsola-Malpighi hospital (Italy). The selected units were: general surgery, general medicine, internal medicine, geriatrics, respiratory physiopathology and pneumology, with a total of 205 beds and around 4,800 admissions per year. Data were collected from the clinical cards and cases of pneumonia were distinguished by origin (community-acquired or hospital-acquired according to CDC definition), individual and clinical characteristics, and aetiology.
The study involved 486 cases of pneumonia: 75 hospital-acquired and 411 community-acquired (84.6%). Patients affected by hospital-acquired pneumonia were older (average age 77 years) compared to community-acquired cases (74 years) and show a more homogeneous gender distribution (males: 48.0% vs 59.4%). Hospital stays (42 vs 21 days) and mortality rates (24.0% vs 11.7%) were significantly higher in hospital-acquired pneumonia. The incidence rate of nosocomial pneumonia was 7.4 per 1000 hospitalized patients and increased to 17-23 per 1000 in the pneumology and respiratory physiopathology units. Only 16.9% of cases had an aetiological diagnosis (14.1% community-acquired; 31.8% hospital-acquired); the most common isolates were S. aureus and P. aeruginosa. The hospital-acquired cases were caused by Gram-negative bacilli more often than the community-acquired cases, and infections were more frequently polymicrobial (37.5% vs 3.4%).
In order to reduce morbidity and mortality due to pneumonia it is important to implement prevention measures in the community (i.e. specific vaccination campaigns), improve clinical protocols for aetiological diagnosis in hospitalised patients and increase epidemiological surveillance of hospital-acquired infections.
Case report
Saccharomyces cerevisiae fungaemia associated to multiple foci pneumonia in a patient affected by alcohol-related hepatic cirrhosis
Montineri Arturo,
Iacobello Carmelo,
Larocca Licia,
La Rosa Rosario,
Nigro Luciano,
Fatuzzo Filippo
Saccharomyces cerevisiae is usually considered non-pathogenic and has rarely been reported as a cause of fungaemia in immunocompromised patients, especially those admitted to an intensive care unit or those affected by acquired immune deficiency syndrome or under immunosuppressive treatment. In all described cases the use of probiotic yeast has been given as the main risk factor. We report a case of S. cerevisiae sepsis complicated by pneumonia in a patient affected by alcohol-related cirrhosis with no evidence of probiotic drug intake. In this case recovery was obtained after a treatment course with liposomal amphotericin B. S. cerevisiae should be taken into consideration when sepsis lacks to isolate any aetiological agent.
Retroperitoneal abscess: an uncommon localization of tubercular infection
Pasqualini Leonella,
Leli Christian,
De Socio Giuseppe V.L.,
Mazzolla Rosanna,
Cavaliere Antonio,
Schillaci Giuseppe,
Bistoni Francesco,
Mannarino Elmo
We describe a rare case of a 29-year-old immunocompetent Nigerian male affected by an abdominal abscess due to Mycobacterium tuberculosis infection. Diagnosis was achieved with cultures from surgical drainage. No pulmonary, renal, or gastrointestinal involvement was identified. The patient was successfully treated with standard four-drug antitubercular therapy.
Isolated laryngeal leishmaniasis in an immunocompetent patient: a case report
Tiseo Domenico,
Tosone Grazia,
Conte Maria Carmela Domenica,
Scordino Fabrizio,
Mansueto Gelsomina,
Mesolella Massimo,
Parrella Giovanni,
Pennone Raffaella,
Orlando Raffaele
La leishmaniosi viscerale, una malattia protozoaria causata da Leishmania infantum, è endemica nel bacino mediterraneo, particolarmente nelle regioni italiane meridionali e tirreniche. L’agente etiologico può sporadicamente causare una infezione primitiva isolata, a livello laringeo, nei pazienti a rischio, quali forti fumatori o pazienti immunodepressi. La forma laringea è spesso pauci-sintomatica e può quindi sfuggire alla diagnosi. Viene qui descritto un caso di leishmaniosi primitiva localizzata sulla corda vocale sinistra in un maschio adulto italiano immunocompetente, senza significativi fattori di rischio, scoperta grazie all’esame istologico. Ci chiediamo quanti pazienti, che accusano sintomi aspecifici quali disfonia e vivono in aree ove l’infezione da Leishmania infantum è presente, potrebbero in realtà avere una infezione da Leishmania spp.
The Infections in the History of Medicine
Contribution of palaeopathology to defining the pathocoenosis of infectious diseases (Part one)
Sabbatani Sergio,
Fiorino Sirio
Studying the remains of mummies obtained by archaeological research may provide key information concerning historical pathocoenosis. Palaeopathology makes it possible to recognise, characterise and connect different features involved in human pathocoenosis, such as epidemiology, in a historical perspective, and cultural development, via the introduction of new livestock farming techniques and agriculture in general. Several distinct pathologies may produce direct and indirect changes in the skeleton of affected individuals. Therefore bone remains represent very important sources of information to study such diseases.
Changes related to trauma and nutrition deficiency as well as secondary signs, induced by tuberculosis, brucellosis, leprosy, syphilis, malaria, periostitis and aspecific osteomyelitis, persist in bones. In addition, other diseases may cause indirect alterations and subsequent secondary bone in the skeleton via different mechanisms. A secondary bone dimorphism may be induced by poliomyelitis. Aspecific lesions may arise in a skeletal bone and then cause secondary alterations in near-bone segments.
Reviewing studies of palaeohistological and palaeopathological research found in the literature, we emphasize the relationship between the appearance of major infectious diseases and the development of human activities; whereas it is clear that the introduction of livestock farming had a key role in the pathocoenosis of distinct infections such as tuberculosis, brucellosis and leprosy, some doubts and uncertainty remain in relation to the origin of others with epidemiologically important pathologies, such as syphilis.
