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Mastronardi M, Cavalcanti E, Labarile N, Armentano R, Gabriele F, Curlo M. Pyoderma gangrenosum in ulcerative colitis patient treated with vedolizumab: adsorptive granulocyte/monocyte apheresis as a new therapeutic option refractory cases - a case report and literature review. Ther Adv Chronic Dis 2023; 14:20406223231194190. [PMID: 37928629 PMCID: PMC10623906 DOI: 10.1177/20406223231194190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/25/2023] [Indexed: 11/07/2023] Open
Abstract
Extraintestinal manifestations occur rather frequently in ulcerative colitis (UC) and Crohn's disease patients and are usually related to an exacerbation of the underlying intestinal bowel disease but sometimes may run a course independent of the inflammatory bowel diseases (IBD). About one-third of patients with IBD develop extraintestinal manifestations, such as pyoderma gangrenosum (PG). PG is an uncommon inflammatory skin disorder of unknown pathogenesis. There are no specific serological or histological markers, and diagnosis is predominantly clinical. Topical and systemic therapies are both vital aspects of treatment and immune modulators have been used with increasing success in recent years, although immunosuppressive drugs raise some concerns due to an increased risk of serious and opportunistic infections and cancer, particularly in elderly and comorbid patients, underlining the unmet need for safer alternative therapies. Thus, in this case report, we highlighted an adsorptive granulocyte/monocyte apheresis (GMA) as a new therapeutic possibility in IBD patients with extraintestinal manifestations. We report a case of a 60-year woman with a history of UC with a Mayo grade 3 score which was associated with a PG. Given that the patients maintained clinical remission with vedolizumab, we preferred not to perform a combined treatment with other antitumor necrosis factor-alpha or ciclosporin, thus avoiding an increased risk of serious infections in the patient. Therefore, we performed the extracorporeal leukocyte apheresis. The patient progressed favorably, with progressive improvement of skin and bowel disease. Therefore, adsorptive GMA has a very favorable safety profile and has been confirmed in numerous studies. In this study, we underlined that an intensive regimen of GMA paves the way to an ideal option for patients with severe and refractory PG complicated with UC.
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Affiliation(s)
- Mauro Mastronardi
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Elisabetta Cavalcanti
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Via Turi 27, Castellana Grotte, Bari 70013, Italy
| | - Nunzia Labarile
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Raffaele Armentano
- Histopathology Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Francesco Gabriele
- Intensive Therapy Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Margherita Curlo
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
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Gnesotto L, Mioso G, Alaibac M. Use of granulocyte and monocyte adsorption apheresis in dermatology (Review). Exp Ther Med 2022; 24:536. [PMID: 35837066 PMCID: PMC9257973 DOI: 10.3892/etm.2022.11463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Abstract
Adsorptive granulocyte and monocyte apheresis (GMA) is an extracorporeal treatment that selectively removes activated myeloid lineage leukocytes from peripheral blood. This technique consists of a column with cellulose acetate beads as absorptive leukocytapheresis carriers, and was initially used to treat ulcerative colitis. A literature search was conducted to extract recently published studies about the clinical efficacy of GMA in patients with different skin disorders, reporting information on demographics, clinical symptoms, treatment and clinical course. Dermatological diseases, in which GMA has been performed, include generalized pustular psoriasis, pyoderma gangrenosum, palmoplantar pustular psoriasis, Behcet's disease, Sweet's syndrome, adult-onset Still's disease, impetigo herpetiformis, reactive arthritis, acne and hidradenitis suppurativa syndrome, cutaneous allergic vasculitis and systemic lupus erythematosus. In most patients, GMA was started after the failure of conventional therapeutic options and it was helpful in the majority of cases. Based on the information summarized, GMA could be considered a valid non-pharmacological treatment option for patients with several dermatological conditions, which are difficult to treat with other pharmacological preparations.
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Affiliation(s)
- Laura Gnesotto
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
| | - Guido Mioso
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
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de Carpi JM. Granulocyte and monocyte/macrophage apheresis in paediatric patients with ulcerative colitis: a case series in Spain. Drugs Context 2022; 11:2021-10-6. [PMID: 35371271 PMCID: PMC8932247 DOI: 10.7573/dic.2021-10-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/27/2022] [Indexed: 11/21/2022] Open
Abstract
Paediatric ulcerative colitis (UC) can cause malnutrition and growth retardation but its treatment can be limited by the potential adverse events of corticosteroids and anti-TNF agents in children. However, adsorptive granulocyte monocyte/macrophage apheresis (GMA) using Adacolumn® reduces intestinal inflammation through multiple immunomodulatory effects. This case series shows the safety and efficacy of GMA in paediatric UC, illustrating several GMA uses: in chronically active UC, for corticosteroid reduction in steroid-dependent UC, in UC with secondary loss of response to anti-TNF therapy, as bridge therapy in UC with failure of anti-TNF therapy, and to substitute toxic drug treatments.
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Affiliation(s)
- Javier Martin de Carpi
- Unit for Integral Care of Paediatric Inflammatory Bowel Disease, Gastroenterology, Hepatology and Nutrition Department, Hospital Sant Joan de Déu, Barcelona, Spain
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Kawai M, Kawanami C, Fukuda A, Seno H. Pyoderma gangrenosum with primary sclerosing cholangitis-associated colitis successfully treated with concomitant granulocyte and monocyte adsorption apheresis with corticosteroids. Clin J Gastroenterol 2021; 14:1561-1566. [PMID: 34101129 DOI: 10.1007/s12328-021-01460-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
An 18-year-old woman was admitted to our hospital with fever, diarrhea and painful skin ulcers in both pretibial areas starting 19 days earlier. The skin lesions appeared deep necrotic ulcers with violaceous undermined borders. She had been diagnosed as ulcerative colitis and primary sclerosing cholangitis (PSC) 6 and 5 years before, respectively, and had stopped having regular check-up and refused medication for years. Her clinical history and skin lesions led us to suspect of pyoderma gangrenosum (PG). The skin biopsy showed aseptic abscess formation with neutrophils infiltration in the dermis without bacteria. Thus, she was diagnosed with PG. 1 mg/kg/day of prednisolone was administered and ten sessions of granulocyte and monocyte adsorption apheresis (GMA) were started. Magnetic resonance cholangiography showed multifocal bile duct strictures due to PSC. Total colonoscopy revealed ulcerative pancolitis with spared normal mucosa in the rectum. After the treatments, her symptoms and the skin lesion improved dramatically. She was discharged on the 45th day with 25 mg/day of prednisolone. In conclusion, this is the first reported case of PG with PSC-associated colitis that showed dramatic response to the concomitant GMA therapy with corticosteroids. Together with previous reports, concomitant GMA therapy with corticosteroids may be an effective treatment for PG.
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Affiliation(s)
- Munenori Kawai
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Syogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Chiharu Kawanami
- Department of Gastroenterology, Otsu Red Cross Hospital, Otsu, Shiga, Japan
| | - Akihisa Fukuda
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Syogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Syogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Leukocytapheresis in patients with inflammatory bowel diseases. GASTROENTEROLOGY REVIEW 2021; 6:99-105. [PMID: 34276835 PMCID: PMC8275965 DOI: 10.5114/pg.2021.106658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 06/30/2020] [Indexed: 11/17/2022]
Abstract
Leukocytapheresis, a blood purification therapy, exerts anti-inflammatory effects by removing activated leukocytes from the peripheral blood through extracorporeal circulation. It is a potential option of treatment for patients with inflammatory bowel diseases (IBD), especially those with ulcerative colitis (UC), who do not respond to conventional therapy. Given that it has a favourable safety profile and seems to have steroid sparing effects, its position in the treatment of UC is likely to expand. However, there is inadequate evidence to draw any conclusions about the efficacy of leukocytapheresis in patients with Crohn's disease, and it should only be used in accordance with special arrangements for consent. Considering the current level of knowledge, it is essential to conduct large, well-designed, randomized clinical trials to evaluate the effects of leukocytapheresis in the management of IBD patients.
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Iwahashi K, Kuroki Y, Takano Y, Nagahama M. Effective use of switching biologics for ulcerative colitis complicated with pyoderma gangrenosum and primary sclerosing cholangitis. BMJ Case Rep 2021; 14:14/5/e241744. [PMID: 33958364 PMCID: PMC8103836 DOI: 10.1136/bcr-2021-241744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although prednisolone, granulocyte/monocyte apheresis, calcineurin inhibitor and anti-tumour necrosis factor (TNF) therapy are generally used, no treatment strategy for inflammatory bowel disease complicated with pyoderma gangrenosum (PG) has been established yet. Herein, we present the case of a 29-year-old man with ulcerative colitis (UC) complicated with primary sclerosing cholangitis. When UC relapsed and PG developed, prednisolone and granulocyte/monocyte apheresis were used; however, their therapeutic effects were deemed insufficient. After 2 weeks, adalimumab (ADA) induced remission; however, his UC and PG relapsed 20 weeks later. As a result of switching to infliximab, since a loss of response to ADA was deemed to have occurred, remission was reintroduced and subsequently maintained for 40 weeks. We conclude that anti-TNF-α antibodies might be selected as the first choice when PG and UC are refractory to treatment, and a switch to anti-TNFs should be considered when the effect is still insufficient.
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Affiliation(s)
- Kenta Iwahashi
- Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yuichiro Kuroki
- Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yuichi Takano
- Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
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Shibuya T, Haga K, Saeki M, Haraikawa M, Tsuchihashi H, Okahara K, Nomura O, Fukushima H, Murakami T, Ishikawa D, Ikeda S, Nagahara A. Pyoderma gangrenosum in an ulcerative colitis patient during treatment with vedolizumab responded favorably to adsorptive granulocyte and monocyte apheresis. J Clin Apher 2020; 35:488-492. [PMID: 32767842 DOI: 10.1002/jca.21821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 12/31/2022]
Abstract
Pyoderma gangrenosum (PG) is an extra-intestinal skin lesion in inflammatory bowel disease (IBD) as is erythema nodosum. Vedolizumab (VED) is a monoclonal antibody that targets α4β7 integrin and has an intestinal selective mechanism. Despite good therapeutic effects on colitis, the effect on extra-intestinal manifestations (EIMs) remains unclear. Here we report a case of ulcerative colitis complicated by PG during treatment with VED, which was successfully treated with prednisolone in combination with adsorptive granulocyte and monocyte apheresis (GMA). The patient was a 50-year-old woman with a past medical history of extensive ulcerative colitis managed by golimumab (GLM). She developed flare symptoms due to loss of response to GLM, and treatment was switched to VED. Her gastrointestinal symptoms were improved with VED treatment with less frequent bowel movements. However, infiltrative erythema with pain appeared on the right lower leg and right knee, and expanded and gradually ulcerated. Her skin lesions were treated with corticosteroid, but showed poor improvement. Therefore, granulocyte and monocyte apheresis (GMA) treatment was administered in combination with prednisolone. After 3 months, the ulcer gradually improved, and at the time of this writing, the eruptions were nearly replaced by epithelial tissue. This case study showed that patients with UC and EIMS may respond well to combination therapy of VED and GMA. GMA has a very favorable safety profile. On the other hand, the causal connection between VED and PG is still unclear. We believe that a combination therapy involving VED and GMA in IBD patients with EIMs warrants consideration.
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Affiliation(s)
- Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keiichi Haga
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Michio Saeki
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Mayuko Haraikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hitoshi Tsuchihashi
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Koki Okahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shigaku Ikeda
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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Tominaga K, Kamimura K, Sato H, Ko M, Kawata Y, Mizusawa T, Yokoyama J, Terai S. Cytapheresis for pyoderma gangrenosum associated with inflammatory bowel disease: A review of current status. World J Clin Cases 2020; 8:2092-2101. [PMID: 32548138 PMCID: PMC7281039 DOI: 10.12998/wjcc.v8.i11.2092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/27/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous. As it is frequently associated with inflammatory bowel diseases, including ulcerative colitis, gastroenterologists should be familiar with the disease including therapeutic options. Therefore, we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases. A literature search was conducted to extract studies published in the last 20 years, with information on demographics, clinical symptoms, treatment, and the clinical course from a total of 22 cases reported and our recent case. In most patients, cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids, antibiotics, immunosuppressive agents and immunoglobulin. Based on the information summarized, cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter, randomized trial.
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Affiliation(s)
- Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Masayoshi Ko
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Yuzo Kawata
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Takeshi Mizusawa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
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Iida T, Hida T, Matsuura M, Uhara H, Nakase H. Current clinical issue of skin lesions in patients with inflammatory bowel disease. Clin J Gastroenterol 2019; 12:501-510. [PMID: 30838512 DOI: 10.1007/s12328-019-00958-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/28/2019] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel disease (IBD) is associated with a number of extraintestinal complications, including skin lesions. Most reports have shown that skin lesions are found in 10-15% of IBD cases, although this depends on the definition of skin lesions. The representative skin lesions in patients with IBD are erythema nodosum, pyoderma gangrenosum, Sweet's syndrome, and so on. These lesions are often associated with IBD progression, and intestinal lesions in particular require appropriate treatment. Recently, another clinical issue regarding skin lesions in patients with IBD, a so-called paradoxical reaction, during the treatment with anti-tumor necrosis factor (TNF)-α agents has emerged. These reactions are termed paradoxical reactions because the skin lesions sometimes resemble psoriasis, although the anti-TNF-α agents have been historically used to treat psoriasis. Paradoxical reactions are reportedly found in approximately 5-10% of patients using anti-TNF-α agents and are no longer rare. Now that the use of biologics is at its culmination, reports regarding paradoxical reactions are predicted to increase in number; thus, we must recognize skin lesions with IBD patients including this type of adverse events and manage them appropriately while consulting with dermatologists.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tokimasa Hida
- Department of Dermatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisashi Uhara
- Department of Dermatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Liu Z, Jiang X, Sun C. The efficacy and safety of selective granulocyte and monocyte apheresis for inflammatory bowel disease: A meta-analysis. Eur J Intern Med 2016; 36:e26-e27. [PMID: 27614377 DOI: 10.1016/j.ejim.2016.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Zhenfei Liu
- Postgraduate Training Base of the General Hospital of Jinan Military Command of Jinzhou Medical University, Jinan, Shangdong, China.
| | - Xueliang Jiang
- Department of Gastroenterology, The General Hospital of Jinan Military Command, Jinan, Shandong Province, China.
| | - Chengcheng Sun
- Postgraduate Training Base of the General Hospital of Jinan Military Command of Jinzhou Medical University, Jinan, Shangdong, China.
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Russo I, Miotto S, Colpo A, Marson P, Tison T, Ferrazzi A, Alaibac M. Successful treatment of pyoderma gangrenosum with granulocyte and monocyte adsorption apheresis. Int Wound J 2016; 14:282-284. [PMID: 27790848 DOI: 10.1111/iwj.12684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 12/14/2022] Open
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis clinically characterised by the presence of painful skin ulcerations with erythematous and undetermined borders and histologically by the presence of neutrophilic infiltrates in the dermis. Granulocyte and monocyte adsorption apheresis, also called granulocytapheresis, is a therapeutic strategy for extracorporeal immunomodulation that selectively removes activated granulocytes and monocytes/macrophages from the peripheral blood. Here, we report a case of a 73-year-old patient affected by a severe form of pyoderma gangrenosum presenting with multiple painful ulcers and pustules on his trunk and extremities. The disease was resistant to high doses of methylprednisolone and methotrexate and successfully treated by granulocyte and monocyte adsorption apheresis. To the best of our knowledge, this is the first report on the efficacy of granulocyte and monocyte adsorption apheresis in pyoderma gangrenosum in Europe.
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Affiliation(s)
- Irene Russo
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Serena Miotto
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Anna Colpo
- Apheresis Unit, University of Padua, Padua, Italy
| | - Piero Marson
- Apheresis Unit, University of Padua, Padua, Italy
| | | | - Anna Ferrazzi
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Mauro Alaibac
- Unit of Dermatology, University of Padua, Padua, Italy
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