Abstract: The diagnostic attitude of western physicians toward migrants' complaints is often an unstable balance between the obstinate search for exotic tropical diseases and the overappreciation of the cultural dimensions of symptoms. Such attitude may divert attention from organic diseases. The careful assessment of all levels of possible misunderstandings (prelinguistic, linguistic, metalinguistic, cultural, and metacultural) may help the physician to discriminate between illness and disease. The long and difficult itinerary leading to the correct diagnosis of congenital myopathy in a migrant from Senegal is described, together with the barriers encountered by the caring staff.
Abstract: Increasing migration flow to Western countries poses formidable challenges from the epidemiological, clinical, and cultural standpoints. A case of Dhat syndrome is presented in a young Pakistani male migrant living in Italy, which required integrated medical and cultural approach to be solved after a through diagnostic workout that did not yield any result.
Abstract: BACKGROUND: Various studies have ascertained different birth outcomes between resident and migrant populations in western countries. Considering preterm delivery (<37 complete weeks of gestation) as a perinatal risk condition, we assessed its rate in migrant and native Italian women who delivered in the main public hospital in Brescia (Italy). METHODS: All migrant puerperas and a random sample of native puerperas hospitalized during the period February to May 2005 were included in the study after informed consent and filled in a self-administered multilanguage questionnaire enquiring about sociodemographic and obstetric data. Additional information including last menstrual period was obtained from personal obstetric records. RESULTS: As many as 471 puerperas entered the study: 366 Italian and 105 migrant women coming from eastern Europe (41.9%), Asia (20%), South America (10.5%), and Africa (27.6%). Of the migrant population, 67 of 105 (63.8%) were at their first delivery in Italy (median interval from arrival: 3.8 y). Gestational age at delivery was assessed for 456 of 471 women (103 migrants and 353 Italians). A total of 36 (7.9%) preterm deliveries were registered: 22 (6.2%) in Italian and 14 (13.6%) in migrant puerperas (p value = 0.015). The highest preterm delivery rate was observed in African women (20.7%), while women from eastern Europe had a similar rate to Italians. In univariate analysis, factors associated to preterm delivery were parity and length of permanence in Italy. We could not demonstrate any correlation with smoking or with a delayed access to antenatal care (first obstetric evaluation after 12 complete weeks of gestation). In multivariate analysis, African origin was the only independent risk factor for preterm delivery [odds ratio (OR) = 3.54; p = 0.018]. CONCLUSIONS: In our setting, preterm delivery occurred more frequently in migrant women, particularly of African origin, and it is not associated to delayed access to antenatal care.
Abstract: BACKGROUND: The identification and treatment of latent tuberculosis infection (LTBI) among immigrants are an effective strategy for TB control in developed countries. A new test for LTBI identification that uses more specific antigens of Mycobacterium tuberculosis is now commercially available under the brand name of QuantiFERON-TB Gold test. OBJECTIVE: To compare QuantiFERON-TB Gold test to tuberculin skin testing (TST) for the detection of LTBI among immigrants from high endemic TB areas. PATIENTS AND METHODS: Undocumented immigrants attending a district medical center were enrolled if they originated from high endemic TB areas, the time of arrival in Italy was < or = 5 years, had neither active TB disease nor known immunodeficiency status. The TST was applied according to standards and QuantiFERON-TB Gold test was performed following the manufacturer's instructions. RESULTS: Hundred subjects were included in the comparative analysis. TST was positive in 44% of subjects; 15% had a positive QuantiFERON-TB Gold test result. The total agreement between TST and QuantiFERON-TB Gold test was 71%, for a kappa statistics of 0.37; agreement was 100% for TST negative results, but only 34% for TST positive ones. In the multivariate logistic regression analysis, previous BCG vaccination was independently associated with a lower chance of disagreement between the tests. CONCLUSION: The prevalence of LTBI among immigrants was lower when determined by QuantiFERON-TB Gold; this may be a consequence of more specific MTB antigens used. Our results suggest that QuantiFERON-TB Gold may be used as confirmatory test for TST positive immigrants candidate to preventive therapy.
Abstract: BACKGROUND: Tenofovir with full-dose didanosine has been associated with paradoxical CD4 + T cell decrease despite virological suppression. We investigated whether tenofovir plus didanosine at a weight-adjusted dosage could be responsible for such an effect, and factors associated with CD4 + T cell count evolution under this combination. METHODS: This was a prospective observational multicohort study (Italian MASTER and Spanish Hospital Carlos III HIV cohorts). Patients with HIV plasma viral load suppression for >/= 6 months who switched to an antiretroviral combination including tenofovir plus didanosine were studied, as long as virological success was maintained. CD4 + T cell count variations over time (slopes) were compared before and after switching to tenofovir plus didanosine using linear mixed models and segmented regression analysis. RESULTS: Annual time-weighted CD4 + T cell count slope did not change significantly after the prescription of tenofovir plus didanosine: it was 14 cells/mm(3) [95% confidence interval (CI) - 7 to 35] from month - 24 to month - 12, 12 cells/mm(3) (95% CI - 14 to 38) from month - 12 to the time of switching, 30 cells/mm(3) (95% CI 5-55) from switching to month + 12 and 15 cells/mm(3) (95% CI - 8 to 39) from month + 12 to month + 24 after switching to tenofovir plus didanosine. No significant change in the slope of the segment after the switch to tenofovir plus didanosine-containing regimens when compared with the segment preceding the intervention was found (CD4 + T cell count slope change: 24 cells/mm(3); 95% CI - 10 to 58). Similar results were obtained using CD4 + T cell percentage over total lymphocytes. The significant independent predictors of lower CD4 + T cell count slope were older age (P = 0.006), lower nadir CD4 + T cell count (P < 0.001) and positive hepatitis C virus antibody (P = 0.03). Moreover, reduced estimated creatinine clearance was an additional independent predictor of lower CD4 + T cell count slope (P = 0.02), but only after excluding nadir CD4 + T cell count. CONCLUSIONS: Tenofovir plus didanosine (weight-adjusted dosage) was not associated with paradoxical CD4 + T cell decrease in our patients maintaining undetectable HIV plasma viral load for a maximum of 24 months after switching. Several factors could explain variability in CD4 + T cell count evolution in these patients.
Abstract: Merkel cell carcinoma (MCC) is a skin cancer of neuroendocrine origin that occurs most often in sun-exposed areas. In the general population, it is a disease of older adults, with only 5% of cases occurring below the age of 50 years. Immunosuppression is the significant risk factor for the development of MCC and recently it was suggested that individuals with HIV have a relative risk of 13.4 to developed MCC in comparison with the general population. We report a case of MCC in an HIV-infected patient and we review nine patients with HIV with MCC. Our patient was a 54-year-old man who came to our attention without a known HIV diagnosis. He was apparently in good health and had no risk factor for HIV, but by the atypical site of the lesion and by the relative young age of the patient we suspected a case of immunosuppression and for this reason we did HIV test that had a positive result. The patient was treated with surgery and chemotherapy but died as a result of liver metastases 25 months after his tumor was diagnosed.
Abstract: Our aim was to evaluate the prevalence of HIV infection in immigrants hospitalised in infectious disease settings in Italy during 2002. Each participating centre filled in a CRF which regarded the number of immigrants hospitalised in ordinary regime or in day-hospital during 2002 and, for HIV-positive patients only, some demographic (age, sex, origin) and clinical features (only HIV positivity or AIDS, new diagnosis or not, diagnosis of opportunistic infections). A total of 46 Infectious Diseases Units participated in the study and a total number of 2255 patients were tested for anti-HIV, irrespective of the cause of hospitalization, with 378 (16%) cases of positivity. Women accounted for 47.9%; the mean age of the population was 34.5 years. African patients showed a higher prevalence of HIV infections than subjects from other geographical areas (61.9% of all cases). Most HIV-infected patients were unaware of their positivity. In conclusion, HIV infection represents one of the main health problems among immigrants, particularly of African origin.
Abstract: Since 1996, AIDS has declined in the Italian population, but cases in foreign patients, including both recent immigrants and long-term residents, have increased from 3.9% in 1995-1996 to 15.4% in 2001-2002. This increase can only be partly explained by a higher migratory flow and might reflect a delayed access to health facilities and to antiretroviral therapy in migrants. We performed a survey for the year 2003 of HIV-infected immigrants to Italy from countries outside the European Union to verify which factors might influence a lack of access to highly active antiretroviral therapy (HAART). Italian centers of infectious diseases were requested to send sociodemographic and clinical data of HIV-infected immigrant patients. A total of 553 HIV-infected immigrants (49.9% women) were evaluated, representing 6.5% of all HIV-infected patients from these centers. The mean duration of residency in Italy was 6.6 +/- 5.0 years. The country of origin was Africa (64.5%), North and South America (24.2%), Eastern Europe (7.0%), and Asia (3.8%). A total of 407 of 553 patients (73.6%) were taking antiretroviral drugs at the time of screening. Females presented a younger age (p = 0.001), a lower frequency of Centers for Disease Control (CDC) stage B/C (p = 0.008) and a more frequent heterosexual exposure to HIV (p < 0.001), while no differences were observed for time of first positive serology (p = 0.7). CD4 cell count (p = 0.9) and log plasma HIV-RNA (p = 0.1). Characteristics of HAART patients were compared to those of nontreated patients, despite a CD4 cell count less than 350 cells/mm(3). No significant difference was found for gender, country of origin, risk factor, and years of Italian residence, while legal immigrants (p = 0.018) and registered in the National Health Service (p = 0.014) were significantly more likely to receive HAART compared to illegal immigrants.
Abstract: A 45-year-old woman was admitted to the hospital because of cholestatic liver disease and severe thrombocytopenia following a 4-day history of fever and malaise. In her childhood the patient suffered from acute rheumatic fever with secondary mitral stenosis. Three years before admission, an atrial fibrillation had been diagnosed for which the patient was put on ticlopidine, 250 mg daily, that was taken regularly, without any adverse event. The patient had no history of cholestatic hepatitis or biliary colic. The abdominal ultrasonography was negative for biliary tract diseases and histological features were compatible with drug induced hepatotoxicity. Laboratory tests for viral and bacterial infection were negative. No other medications, apart from 2 doses of nimesulide, had been taken by the patient in the previous days. Ticlopidine was discontinued on admission and both bilirubin and platelet count rapidly normalized. We think that, in our patient, ticlopidine may be responsible of concomitant hematologic and hepatic toxicity and the trigger event might have been the reduced renal excretion of the drug following acute renal failure.
