Giuseppe V. L. De Socio, MD, PhD Clinica di Malattie Infettive, Università di Perugia Ospedale "Santa Maria della Misericordia" via Menghini, 1 – 06129 Perugia, Italy Phone: +39-075-5784321 • Fax: +39-075-5784346 •
Abstract: Malignant syphilis is now considered a rare disease, more commonly affecting individuals with poor health, malnutrition or HIV infection. We present a 34-year-old man with HIV infection who developed multiple atypical cutaneous ulcerations, leonine facies, a scleral nodule and keratitis with visual loss. The diagnosis of malignant syphilis was delayed due to the insidious presentation, but was confirmed via immunohistochemical (IHC) staining with anti-Treponema antibodies of a skin biopsy. Significant clinical improvement was observed following a 15-day course of penicillin and tigecycline therapy. In advanced HIV disease, cutaneous manifestations are often difficult to identify and present a challenge for the clinician. Clinical manifestations of secondary syphilis vary greatly, earning the epigram of 'the great imitator'. It is important to recognize atypical presentations of syphilis, especially among HIV-infected individuals. Unlike historical cases of malignant syphilis, Treponema pallidum was found in the tissue section using IHC staining methods. We emphasize the importance of lues maligna in the differential diagnosis of HIV-infected patients with diffuse ulceronodular lesions as well as the usefulness of histological investigations and IHC studies.
Abstract: A case of retrobulbar monolateral optic neuritis due to disseminated Cryptococcosis in a 32-year-old man with a new diagnosis of AIDS is described in the era of combination antiretroviral therapy (cART). The patient presented a monolateral rapid visual loss on day 7 of a liposomal amphotericin B treatment. Neuroradiological imaging showed the presence of retrobulbar neuritis. After starting ART and intravenous metilprednisolone 1 g daily for 3 days, we assisted to a progressive improvement of visual acuity. At 3 months of follow-up, complete clinical resolution was obtained. In this case, in the presence of effective antiretroviral and antifungal treatment, a short course of metilprednisolone was a safe therapy.
Abstract: Osteonecrosis (ON) is a rare disabling complication occurring in patients with human immunodeficiency virus (HIV) infection at a higher frequency than in the general population despite effective combination antiretroviral therapy being made available, as recently documented by several retrospective studies. We designed a multicentric case-control study among HIV-infected patients cared for at institutions in the Italian CISAI group (Italian Study Group for Adverse Events in HIV Infection) to search for additional predictors of ON in this special population. All centers which observed at least one case of ON were requested to report data for central re-evaluation. Parallel HIV-positive, ON-free controls were randomly selected and matched with confirmed cases of ON for sex, age and CD4 T-cell counts at the time of HIV diagnosis. Fifteen cases and controls were included in the final sample. Univariate statistical analyses revealed a significant association between ON and exposure to steroids (PÂ =Â 0.001), exposure to one or more drugs in addition to HAART (Highly Active Anti-Retroviral Therapy) (PÂ =Â 0.03), high titers of total serum IgE (PÂ =Â 0.02), loss of working ability (PÂ =Â 0.03), triglycerides levels over 200Â mg/dL before antiretrovirals (PÂ =Â 0.03) and cholesterol levels over 200Â mg/dL before and after antiretrovirals (PÂ =Â 0.03 and 0.05, respectively). High serum IgE levels and loss of working ability in advance of ON appeared for the first time as possible predictors of ON in HIV patients, while long-term exposure to steroids, combined hyperlipemia and chronic treatment with other drugs in addition to antiretrovirals were confirmed. Predicting and preventing ON in the individual HIV-infected patient is therefore a clinically challenging opportunity.
Abstract: Hepatitis B virus (HBV) infection constitutes a serious global health problem. Nowadays there are divergent data regarding the use of antiviral drugs to treat acute hepatitis B. We present here a case of a 62-year-old man affected by severe acute hepatitis B with progressive worsening of clinical and hepatic function. The patient was treated with entecavir without critical side effects. We observed rapid clinical and laboratory improvements and the disappearance of hepatitis B surface antigen (HBsAg). The treatment with entecavir was protracted until 17(th) week when the antibody anti-HBs appeared. Entecavir should be carefully considered for the treatment of severe acute hepatitis B cases.
Abstract: An attenuation of the physiological day-night blood pressure (BP) reduction is an important predictor of cardiovascular (CV) events and death. We compared circadian BP profile in treatment-naive HIV-infected patients and in healthy control subjects.
Abstract: The aim of the study was to evaluate the cardiovascular risk factors associated with subclinical carotid atherosclerosis in antiretroviral therapy-naïve HIV-infected patients. The HERMES (HIV Exposure and Risk of Metabolic Syndrome) study enrolled therapy-naïve patients attending hospitals in the Italian coordination group for the study of allergies and HIV infection (CISAI [Coordinamento Italiano per lo Studio Allergia e Infezione da HIV]) in 2007. It was designed to identify metabolic syndrome (MS) and cardiovascular risk factors. The present analysis is a nested cross-sectional study with a subset of patients examined by carotid ultrasonography. Consecutive antiretroviral therapy-naïve HIV patients attending the facilities involved in the CISAI were included. Their 10-year probability of cardiovascular events was calculated using the Framingham Risk Score (FRS) and three other cardiovascular algorithms (the Global Framingham Risk Score - GFRS, 'Progetto Cuore' and 'SCORE'). Vascular age was estimated using a new model derived from GFRS and was compared with chronological age. The diagnosis of MS was based on the National Cholesterol Education Programme and International Diabetes Federation (IDF) definitions. Subclinical atherosclerosis was determined as ultrasound carotid intima-media thickness >0.9 mm. Out of 140 patients enrolled in the HERMES study by the four centres participating in the nested study, a total of 72 (51.4%) subjects, with no overt cardiovascular disease, were examined using carotid ultrasonography. The median age was 40 years, 79.2% men. The vascular age was 7.6 years higher than the chronological age. The factors associated with subclinical atherosclerosis were age (P < 0.0001), vascular age (P = 0.0002), body mass index (P = 0.003), waist circumference (P = 0.0002), MS (IDF definition, P = 0.004) and all the cardiovascular (CV) models (FRS, P = 0.01, GFRS, P = 0.002, Progetto Cuore, P = 0.018, SCORE, P = 0.03). Independent of other significant factors, waist circumference was significantly associated with pathological results (P = 0.007). The GFRS (area under the receiver-operating characteristic curves, 0.78; P < 0.001) had slightly better predictive accuracy than the other three CV models (FRS, areas under the curve [AUC] = 0.71, P = 0.003; Progetto Cuore, AUC = 0.74, P = 0.0005; SCORE, AUC = 0.77, P < 0.0001); 55% of patients at intermediate risk (6-20%) had subclinical carotid lesions. Subclinical carotid lesions had a highly significant direct association with all the CV risk predictors. The GFRS and vascular age were highly predictive. We recommend a carotid ultrasonographic examination at least among HIV patients with GFRS > or =6% or with an elevated waist circumference.
Abstract: HERMES is a prospective study, including all treatment-naïve patients attending scheduled visits at hospitals in the CISAI group in 2007. The present cross-sectional analysis aims to assess the baseline prevalence and characteristics of Metabolic Syndrome (MS) in a population of HIV-positive treatment-naïve patients. MS was diagnosed using the National Cholesterol Education Program (NCEP) definitions. A total of 292 subjects were enrolled, median age was 37 years, 75% of them were males. The prevalence of MS was 12.3%. The most frequent trio of abnormalities that led to the diagnosis of MS was high blood pressure, triglycerides and HDL. Univariate analysis showed that MS was associated with the following variables: age, education, physical activity, advanced HIV disease (CDC stage C or HIV-RNA >100,000 copies + CD4 <100 cells/mm(3)). Higher educational levels remained protectively associated with MS in multivariate analysis. A higher risk of MS was also associated with advanced HIV disease. Actually, treatment-naïve HIV-positive patients in an advanced stage of the disease have a higher prevalence of abnormal levels of triglycerides, HDL cholesterol and blood glucose than those at a less advanced stage. These findings of the HERMES study suggest, therefore, that HIV infection per se is associated to MS.
Abstract: Various studies have been conducted to evaluate the role of antiretroviral therapy in the onset of cardiovascular risk among HIV-1-infected patients, while fewer data are available regarding antiretroviral-naïve patients. Our objective was to evaluate the cardiovascular risk among naïve subjects examining traditional risk factors, immunovirologic parameters, assessing the Framingham risk score (FRS), and detecting the presence of subclinical carotid lesions by means of color Doppler ultrasonography. One hundred seventy-two antiretroviral-naïve patients underwent color Doppler ultrasonography. An intima-media thickness (IMT) greater than 0.9 mm and/or atherosclerotic plaques were considered pathologic findings. Demographic, immunovirologic data, and risk factors for cardiovascular disease were collected. The 10-year probability of acute coronary events was assessed by the FRS. The statistical analysis was performed using t test and chi(2), Fisher's test, and conditional multiple logistic. Thirty-six patients (20.9%) had lesions at ultrasonographic investigation. The presence of lesions was significantly related to male gender (p = 0.005), age (p = 0.003), sedentary life (p = 0.05), Centers for Disease Control and Prevention (CDC) group C or CD4(+) less than 150 cells/mm(3), and viral load (VL) > 100,000 copies per milliliter (p = 0.04). The presence of subclinical carotid lesions showed a highly significant direct association with the estimated FRS (p < 0.002). The presence of subclinical atheromasic lesion results was also high among antiretroviral-naïve patients. FRS is highly predictive of the lesions, but also an advanced stage of disease plays a significant role. Our data support the hypothesis that HIV infection per se is a risk factor for atherosclerosis. We recommend an ultrasonographic assessment both among patients with FRS 6% or more and among those in advanced stage of disease.
Abstract: A case of Fusobacterium nucleatum endocarditis in an 80-year-old man is reported. The patient presented with a headache and nonspecific musculoskeletal symptoms and was misdiagnosed as having polymyalgia rheumatica. The diagnosis of bacterial endocarditis was delayed because of an insidious presentation, typical in infections with low virulence micro-organisms. The musculoskeletal symptoms, unresponsive to protracted corticosteroids, completely resolved with intravenous ampicillin treatment. Rheumatologic symptoms may hinder the correct diagnosis of subacute infective endocarditis. An atypical evolution of a common rheumatic disorder such as polymyalgia rheumatica should alert physicians to the possibility of bacterial endocarditis.
Abstract: OBJECTIVE: To evaluate the prevalence and incidence of nephrotoxicity in HIV-infected patients enrolled in the SCOLTA Project tenofovir cohort and to identify possible risk factors. DESIGN: The SCOLTA Project is a prospective, observational, multicenter study involving 25 infectious disease departments in Italy created to assess the incidence of severe adverse events in patients receiving new antiretroviral drugs. PATIENTS: The SCOLTA Project tenofovir cohort includes a total of 754 HIV infected patients. RESULTS: Data including grade II-IV creatinine elevations according to ACTG scale were available in 354 patients, 237 (67%) males with a mean age of 40.1+/-7.6 years enrolled in the SCOLTA Project tenofovir cohort. During a mean follow up of 19.5+/-11.5 months creatinine elevations were reported in 9/354 (2.5%) patients, all males. Mean duration of tenofovir therapy at the event was 9.5+/-5 months. The overall incidence was 1.6 (95% CI 1.5-1.7) per 100 person-years (p-y) and 0.5 (95% CI 0.4-0.6) p-y for grade III. No grade IV creatinine elevations were reported. Patients with nephrotoxicity were older and more frequently male, HCV infected, in CDC stage C and their CD4 cell count was significantly lower than those without nephrotoxicity. No significant difference was found between tenofovir co-administered antiretroviral drugs. CONCLUSIONS: Both prevalence and incidence of nephrotoxicity were low in patients receiving tenofovir in a non-selected clinical setting. Renal injury in patients receiving tenofovir seems associated with the presence of co-morbidities and with advanced HIV infection.
Abstract: OBJECTIVE: To identify and characterize HIV-infected patients at higher cardiovascular risk in ordinary clinical settings. DESIGN: Multicenter, nationwide cross-sectional study. METHODS: Consecutive HIV-patients, attending scheduled visits at facilities involved in the Italian coordination group for the study of allergies and HIV infection (CISAI), were included between February and April, 2005. Their 10-year probability of acute coronary events was calculated using the Framingham Risk Score (FRS) as well as 3 other cardiovascular algorithms ("PROCAM", "PROGETTO CUORE", "SCORE"); Metabolic Syndrome (MS) was diagnosed according to the National Cholesterol Education Program definitions. An estimated 10-year CVD >or=10% and/or MS led to the diagnosis of high CV risk. We compared selected clinical features between high- and low-risk patients. RESULTS: A total of 1230 HIV infected patients (72% males, mean age of 43+/-9 years), 185 of whom treatment-naive, were evaluated. FRS gave the highest estimate of CV risk. The mean 10-year risk for acute coronary events according to FRS was 7.4+/-7.0. MS was present in 22% of the observed patients. Accordingly, 443 patients (36%) were classified at high risk. Twelve percent of the patients (n=142) had both a FRS >or=10% and a diagnosis of MS. The main single predictor of increased cardiovascular risk was smoking (60% of whole sample). A higher prevalence of clinically evident lipodystrophy and a higher CD4 T-cell counts were found both in patients with higher FRS and in patients with high FRS and MS (both p<0.001). CONCLUSIONS: The worst estimation of CV risk was obtained with the FRS algorithm. Clinical evidence of lipodystrophy and higher CD4 T-cell counts were closely associated to a worse cardiovascular risk profile.
Abstract: HIV infection is associated with chronic immune activation, subclinical inflammation, and an atherogenic metabolic profile. It remains controversial whether HIV infection is a risk factor for accelerated arteriosclerosis independent from the effects of antiretroviral drugs. We investigated whether aortic stiffness, an early marker of arteriosclerosis, is increased in HIV patients who were not under antiretroviral treatment. In 39 untreated HIV-infected patients and 78 individually matched age-, sex-, and blood pressure-matched HIV-uninfected control subjects, we determined aortic pulse wave velocity (PWV), a direct noninvasive measure of aortic stiffness, by tonometric method. Subjects with overt cardiovascular disease or major cardiovascular risk factors were excluded from the study. Prevalence of the metabolic syndrome was higher in HIV patients (18% versus 5%; P=0.025). HIV patients had a higher aortic PWV (7.5+/-1.4 versus 6.7+/-1.1 m.s(-1); P=0.001) than control subjects. Age, mean arterial pressure as a measure of distending pressure, and HIV infection (all P<0.05) independently predicted aortic PWV when a consistent number of cardiovascular risk factors was simultaneously controlled for. Among HIV-infected subjects, serum gamma-glutamyl transpeptidase concentration (beta=0.46; P=0.003) and mean arterial pressure (beta=0.32; P=0.03) were independent determinants of aortic PWV. In conclusion, aortic stiffness is increased in HIV-infected individuals who have never received antiretroviral therapy. PWV increases with increasing serum gamma-glutamyl transpeptidase concentration. Our data support the hypothesis that HIV infection is a risk factor for arteriosclerosis.
Abstract: Osteoporosis occurs in HIV-infected patients as well as in common psychiatric conditions and causes significant morbidity. There are no published studies assessing bone mineral density (BMD) in institutionalized HIV patients with associated psychiatric disorders. We analyzed 51 subjects in a case control study: 17 HIV patients (males or pre-menopausal females) with psychiatric co-morbidity and a long-term antipsychotic and antiretroviral therapy; and 34 control healthy subjects, not infected with HIV, matched with patients by age and sex. The results show that the HIV group had significantly higher rates of pathological T-scores, as compared with the controls (71% vs. 9% p<0.001). Chronic mental illness may represent a possible important co-factor influencing BMD in HIV patients. We suggest that fracture risk should be carefully evaluated for institutionalized HIV patients with psychiatric co-morbidity.
Abstract: We describe a 42-year-old man with AIDS and Hodgkin's lymphoma whose severe and recalcitrant cutaneous warts resolved following treatment with local 1% cidofovir. Clinically significant improvements were observed in a two-week period of therapy. In advanced HIV disease complicated by additional haematological malignancy, cutaneous warts may be difficult to treat and present a challenge for the attending physicians. In similar clinical condition topical anti-human papillomavirus therapy may prove to be safe and curative.
Abstract: 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.
Abstract: BACKGROUND: It is not known whether antiretroviral therapy (ART) including lopinavir/r has a different effect on the lipid metabolism in HIV patients co-infected with HCV. This study investigated changes in lipid levels, comparing patients with HIV infection alone and those with HCV too, in the lopinavir/r cohort of the SCOLTA project. METHODS: We analyzed the data for the lopinavir/r nationwide cohort from 25 Italian infectious disease departments, which comprises 743 HIV-infected patients followed prospectively, comparing subjects with HIV-HCV co-infection and those with single-infection. RESULTS: At enrolment, co-infected patients had significantly lower mean cholesterol than HCV negative cases (162+/-43mg/dL vs. 185+/-52mg/dL, p=0.0009). Total and non-HDL cholesterol and triglycerides rose significantly from baseline in HIV single-infection patients, but not in those with co-infection. The patients with dual HIV-HCV infection, treated with an ART regimen including lopinavir/r, have only limited increases in total and non-HDL cholesterol and triglycerides. CONCLUSIONS: Changes in serum lipids in co-infected patients differed significantly from those in patients without HCV. It remains to be seen whether this is associated with a lower risk of progression of atherosclerotic disease.
Abstract: Cardiovascular disease (CVD) is an increasing concern for human immunodeficiency virus (HIV)-infected patients, and risk assessment is recommended in routine HIV care. The absolute cardiovascular risk in an individual is determined by several factors, and various algorithms may be applied. To date, few comparisons of HIV patients with persons of the same age from the general population have been conducted. We hypothesized that the calculated risk of CVD may be increased in HIV patients. The probability for acute coronary events within 10 y (Framingham Risk Score) and the probability for fatal cardiovascular disease (SCORE algorithm) were assessed in 403 consecutive HIV-positive subjects free from overt cardiovascular disease, as well as in 96 age- and gender-matched control subjects drawn from the general population living in the same geographical area. The average 10-y risk for acute coronary events (Framingham Risk Score) was 7.0%+/-5% in HIV subjects and 6.3%+/-5% in the control group (p =0.32). The 10-y estimated risk for cardiovascular mortality (SCORE algorithm) was 1.23%+/-2.3% and 0.83%+/-0.9%, respectively (p =0.01). The main contributor to the increased CVD risk was the high proportion of smokers, but not an increase in cholesterol level. In conclusion, a limited increase in estimated risk of CVD was found in HIV-infected patients compared to the general population. In HIV-infected individuals other factors of less value in the general population and not included in any cardiovascular algorithm might be important. In our patients intervention to modify traditional risk factors should be addressed primarily towards modifying smoking habits.
Abstract: HIV-infected patients may undergo renal damage related to the HIV infection itself, to the presence of co-infections, arterial hypertension, diabetes or to the exposure to nephrotoxic drugs. Tenofovir has been associated with the development of acute renal failure with Fanconi syndrome and acute tubular necrosis and, albeit rarely, with chronic liver disease. Patients with low CD4 cell count, low body weight and with concomitant diseases such as arterial hypertension and diabetes or co-infections with HCV, HBV or Treponema pallidum seem at higher risk of tenofovir-related nephrotoxicity. Other risk factors include previous exposure to nephrotoxic drugs and the association of tenofovir with boosted protease inhibitors or with didanosine. However, from the analysis of published papers the incidence of tenofovir-related renal toxicity seems low, as confirmed also by our personal casuistry (SCOLTA Project). Thus, a careful selection of patients including the evaluation of existent renal disease before starting an antiretroviral regimen including tenofovir is necessary to prevent renal damage. Furthermore, frequent monitoring of renal function in patients at higher risk of renal damage is strongly recommended, as well as a tenofovir dose adjustment if an alteration of renal function is detected.
Abstract: BACKGROUND: The role of antiretroviral therapy in acceleration of atherosclerosis in patients with human immunodeficiency virus (HIV) infection is controversial. We hypothesized that aortic stiffness, an early marker of arteriosclerosis, may be increased in HIV patients treated with protease inhibitors. METHODS AND RESULTS: In 32 HIV-infected patients treated with protease inhibitors and 32 age-, sex-, and blood pressure-matched HIV-uninfected control subjects, we obtained aortic pulse wave velocity and central aortic pressure waveform, from which aortic augmentation was calculated. HIV patients had a higher aortic pulse wave velocity (7.6+/-1.1 versus 6.8+/-1.2 m x s(-1), P=0.015) and aortic augmentation (6.8+/-5 versus 4.6+/-4 mm Hg, P=0.037) than control subjects. Age and HIV infection (both P<0.05) independently predicted aortic pulse wave velocity when a consistent number of cardiovascular risk factors was simultaneously controlled for. The cumulative duration of treatment was a predictor of aortic pulse wave velocity, each 5 years of treatment duration being independently related to a 1.35 m x s(-1) increase in pulse wave velocity. CONCLUSIONS: Aortic stiffness is increased in HIV-positive individuals receiving antiretroviral therapy including a protease inhibitor. Pulse wave velocity increases with longer exposure to protease inhibitors. We hypothesize that arteriosclerosis is a side effect of antiretroviral treatment including a protease inhibitor.
Abstract: According to the National Nosocomial Infection Surveillance system we analysed the post-surgical nosocomial infections in a surgery ward of Perugia University. Between May 2000 and April 2001, 677 patients were enrolled mean age 51.5 years: 355 (52%) male, 462 (68%) ASA score 1, "clean" surgery in 355 cases (52%), cephazolin prophylaxis in 256 (38%); 11 (2%) patients deceased perioperatively. A total of 37 nosocomial infections, in 33 patients, were detected: 18 pneumonia (48.6%), 10 surgical site infections (27%) with 18 isolated: 12 gram-negative (E. coli 3, Acinetobacter baumannii 2, Providencia stuartii 2, Pseudomonas aeruginosa 2, Achromobacter spp. 1, Citrobacter freundii 1, Morganella morgani 1) and 6 gram-positive (Staphylococcus aureus meticillin resistant 3, Enterococcus faecalis 2, Streptococcus salivarius 1); 7 sepsis (19%) due to 7 gram-positive (S. aureus meticillin resistant 4, S. aureus meticillin susceptible 1, Staphylococcus coagulase negative 1, Clostridium spp 1), 2 urinary tract infections (5.4%). Patients without infections and with nosocomial infections spent in hospital 6.3 and 16.6 days respectively. We can image that in one year 53 surgical procedure were lost, with a lost gain of 79.500-291.500 euro/year.
Abstract: Most sore throat is due to viral upper respiratory tract infections, whereas the frequency of antibiotic use in adult patients is about 73%. We evaluate the clinical guidelines (approved by the CDC) about appropriate antibiotic use for acute pharyngitis in young adults. We observe a low prevalence (3,2%) of group A beta haemolytic streptococcus (GABHS) in a population of university students. Minimizing unnecessary antimicrobial therapy in this setting is highly desirable. Use of clinical criteria (Centor algorithm) does indeed identify patients whose risk for GABHS infection is so low that microbiological testing or antibiotic treatment is unnecessary.
Abstract: In renal allograft recipients, infection disease complications remain an important cause of morbidity and mortality during the post-transplant period. This complication occurs more frequently from 1 to 6 months after transplant. The epidemiology of infection during the postoperative period is less well characterized, because recipients routinely reside at home. We describe a case of late onset Candida albicans and HSV-1 esophagitis, and Pneumocystis carinii pneumonia, that occurs 9 years after renal transplantation in a patient with severe CD4+ T-lymphocytopenia and hypogammaglobulinaemia. We underline the importance of monitoring immunosuppressive therapy in these patients and the usefulness of prophylaxis against P. carinii pneumonia
Abstract: To determine the relation between endocarditis/septicemia and systemic inflammatory response syndrome (SIRS), septic shock, MODS, we performed a retrospective analysis in 196 HIV-negative patients, with endocarditis/septicemia. No deaths were observed between 20 patients with endocarditis without severe infective SIRS/septic shock. On the other hand among 10 patients with endocarditis with severe infective SIRS/septic shock we registered 3 deaths (P = 0.052). No deaths were registered among 93 patients with septicemia without severe infective SIRS/septic shock. Between 73 patients with septicemia and severe infective SIRS/septic shock 9 (12.3%) patients died and, precisely, 7/61 in severe infective SIRS (11.4%) and 2/.12 (16.6%) in septic shock (P = 0.003). The definition of septicemia according to Schottmüller (1914), as a generalized bacterial infection with a persistent bacteremia is still justified. The term "sepsis" has become ambiguous because it has been used as synonym of "acute response to infection", while in the past and presently, at least in Europe, it is synonym of septicemia, persistent bacteremia. The term of SIRS could avoid the misunderstanding. The words: "infective SIRS", "severe infective SIRS", may label properly the reactive events mounted by the host as a useful defence against infections but they become dangerous and bring about septic shock, organ failure and mortality when excessive.
Abstract: OBJECTIVE: To evaluate the prevalence of hepatitis C virus (HCV) genotypes in a central area of Italy (Umbria); to analyze the correspondence of the genotypes detected in serum and liver samples; to study the relationship between HCV genotypes and severity of liver disease; to test whether co-infection with more than one HCV subtype could be influenced by the source of infection. METHODS: Genotyping by polymerase chain reaction with core-specific primers (Okamoto method) was performed in the serum and liver from 48 consecutive patients with histologically confirmed chronic C hepatitis. RESULTS: HCV genotype 1b was the prevalent strain and was not associated with more severe histologic damage. Data show a very good correspondence between genotypes identified in serum and liver specimens (91%). Mixed infections (with subtypes 1b and 2a) correlated significantly with intravenous drug abuse (p=0.001). CONCLUSION: We confirmed that subtype 1b is prevalent in central Italy. Co-infection with more than one subtype is not rare in intravenous drug abusers.
Abstract: In 1995, 463 patients were admitted in the medical service of Perugia (Sanitary District n. 6). Only 20% of them were enrolled in the TBC programme. Mantoux was: < 10 mm in 35%, 10-15 mm in 25%, > 15 mm in 40%. Chest Rx in 30 subjects demonstrated: normality in 19; old TBC in 7, active TBC in 4 (miliary, bilateral upper lobe pneumonitis, left subapical upper lobe pneumonitis and right lobitis of the upper lobe). All patients were admitted in hospital and showed positive sputum culture for Mycobacterium Tuberculosis. They were treated with isoniazid, rifampin, pyrazinamide, ethambutol/streptomycin for 2 months and with isoniazid, rifampin for other 4-8 months. Two patients showed Mycobacterium tuberculosis with isoniazid resistance. Seven patients were treated with isoniazid chemoprophylaxis without side effects. Migrants should receive information about health care service and be encourage to register themselves with a general practitioner. Skin test screening and chest radiographs for those with positive results should be provided at a convenient location.
Abstract: We studied the prevalence, clinical spectrum and epidemiologic features of thrombocytopenia among 442 (333 male, 109 female) HIV infected patients. Thrombocytopenia was defined as a platelet count < 100,000/mmc and severe if platelet count was < or = 30,000/mmc. Intravenous drug abusers were 83% (369/442). At the first clinical evaluation according to Walter-Reed (WR) classification, 90% (396/442) of patients were in stage 1-5 and 10% (45/442) in stage 6. Severe thrombocytopenia (platelet count < or = 30,000/mmc) was present in 24% (11/45) of the entire thrombocytopenic population. Forty percent (18/45) of the thrombocytopenic patients were positive to: HBV (6), HCV (7), HBV+HCV (5). Mild bleeding was present in 16% (7/45) of the patients but one case, with severe thrombocytopenia, died of intracranial hemorrhage. Major hemorrhagic sequelae with even fatal events are possible, especially when a low platelet count is associated with other hemostatic abnormalities (e.g. haemophilia, liver disease, disseminated intravascular coagulation). Zidovudine therapy (range 500-1250 mg/day) is effective in normalizing the platelet count (platelets > 100,000/mmc) only in 29% (9/31) of the patients.
Abstract: Authors utilized the polymerase chain reaction (PCR) technique to detect the presence of HIV DNA in 31 subjects (12 seropositive patients, 4 seronegative, at risk persons and 15 seronegative, not at risk controls). PCR was highly sensitive (enabling the detection of as few as 10 proviral genomes) and specific. By comparison to known amounts of HIV DNA, it was possible to obtain semiquantitative evaluation. No correlation was found between the proviral amount and the clinical stage of the disease or the p24 antigenemia.
