[Mediterranean spotted fever in paediatric and adult patients: two clinical aspects of the same disease]

Mediterranean Spotted Fever is an acute febrile disease caused by Rickettsia conorii and transmitted to humans by the brown dog tick Rhipicephalus sanguineus. Nearly 400 cases are reported every year in Sicily, mainly from June to September. The aim of this study is to compare the clinical and laboratory features of two different groups of patients , one of adults and one of children. The analysis included all adult patients with MSF diagnosed at the Institute of Infectious Diseases, Paolo Giaccone University Polyclinic in Palermo, during the period January 2007- August 2010 and all the children diagnosed with MSF at the G. Di Cristina Children Hospital in Palermo during the period January 1997- December 2004. On admission, a complete physical and laboratory examination was carried out on every patient. An indirect immunofluorescence assay for Rickettsia conorii was performed in every case, a PCR assay was performed with blood samples from some adult patients. Analysis of the results confirms that MSF is a benign, and self-limiting disease in children, while severe complications can often arise in adults.

Universal varicella vaccination in the Sicilian paediatric population: rapid uptake of the vaccination programme and morbidity trends over five years

Following the licensure of the Oka/Merck varicella vaccine in Italy in January 2003, the Sicilian health authorities launched a universal vaccination programme in all nine Local Health Units. A two-cohort vaccination strategy was adopted to minimise the shift of the mean age of varicella occurrence to older age groups, with the goal of vaccinating with one dose at least 80% of children in their second year of life and 50% of susceptible adolescents in their 12th year of life. Two studies were implemented in parallel to closely monitor vaccination coverage as well as varicella incidence.

Universal varicella vaccination in the Sicilian paediatric population: rapid uptake of the vaccination programme and morbidity trends over five years

Following the licensure of the Oka/Merck varicella vaccine in Italy in January 2003, the Sicilian health authorities launched a universal vaccination programme in all nine Local Health Units. A two-cohort vaccination strategy was adopted to minimise the shift of the mean age of varicella occurrence to older age groups, with the goal of vaccinating with one dose at least 80% of children in their second year of life and 50% of susceptible adolescents in their 12th year of life. Two studies were implemented in parallel to closely monitor vaccination coverage as well as varicella incidence. Overall, the programme achieved its target, with 87.5% vaccine coverage for the birth cohort 2005 and 90.2% for adolescents born in 1995 and 1996. Varicella surveillance data obtained from a total of 28,188 children (0-14 years-old) monitored by family paediatricians showed a decline in incidence rates from 95.7 (95% confidence interval (CI): 72.2-126.8) for 1,000 person-years (PY) in 2004 to 9.0 (95% CI: 6.4-12.6) for 1,000 PY in 2007. In Europe, the only similar experience is the routine childhood varicella vaccination programme in Germany that started in 2004 with a single dose at the age of 11-14 months. The two-cohort universal vaccination programme implemented in Sicily, as well as the network for the surveillance study, can offer a model to other European countries that are considering introducing universal childhood varicella vaccination.

Diagnostic problems and postnatal follow-up in congenital toxoplasmosis

AIM

In order to assess the consequences of different clinical approaches in the prenatal management of congenital toxoplasmosis, we retrospectively reviewed 58 pregnant women with Toxoplasma seroconversion and prospectively enrolled their 59 infants, referred to us from 1999 to 2004.

METHODS

Data on clinical, laboratory and demographic characteristics of the pregnant women were collected. Their children were entered into a 48-month follow-up programme in which clinical, instrumental, ophthalmologic and serologic evaluations were carried out at birth, at 1, 3, 6, 9, 15, 18, 24, 36 and at 48 months of life. Paediatric treatment with Spiramycin alone or alternated with Pyrimethamine-Sulphadiazine was administered according to the different clinical cases.

RESULTS

Time of infection was dated in the first trimester for 24 women (41%), in the second trimester for 18 women (31%) and in the third trimester for 16 (28%). In the first trimester of pregnancy 20 of the 24 infected women had undergone amniocentesis, while the test had not been performed on any of the women infected in the third trimester. Serological follow-up revealed that 11 (19%) of the infants had been infected. An alternating regimen with Pyrimethamine-Sulphadoxine was administered to the infected children. All the infants were clinically asymptomatic, and the instrumental follow-up revealed specific toxoplasmosis anomalies in 4/11 infected children.

CONCLUSION

Our results highlight issues and problems concerning current prenatal diagnostic tests and the therapeutic approach based on PCR testing of amniotic fluid alone. The incidence of ocular-cerebral lesions observed in children born to women with seroconversion in the third trimester raises questions about the diagnostic and therapeutic approach for these women and their offspring. Paediatric therapeutic protocol, with alternating Pyrimethamine-Sulphadiazine regimen, applied also to asymptomatic children born to women with inadequate prenatal diagnostic management, could prevent severe sequelae.

Diagnosis of congenital toxoplasmosis: pre- and post-natal evaluation in Sicilian (Italy) epidemiological area. Preliminary data

To evaluate the usefulness of conventional serological methods with western blot assay (WB) in congenital toxoplasmosis diagnosis, we prospectively enrolled in a clinical and serological follow-up all pregnant women with Toxoplasma gondii infection and their offspring, referred to us from October 2004. Western blot and standard serological test were performed on sera collected from mother during pregnancy and from mother and child at birth, at postpartum month 1-3-6-9 and 12. At this point in time, 22 pregnant women and 14 infants have completed the follow-up. 4 newborns were infected and 2 had specific toxoplasmosis anomalies at the birth. In mothers without seroconversion, the WB performed during pregnancy demonstrates the highest accordance with postnatal follow-up whereas in 1 case the negative result of PCR analysis was not confirmed by postnatal observation. The detection of anti-T gondii IgG against 8 kDa accessory antigenic band and against the accessory band included between 35 and 40 kDa band in immunoblot assay was useful for diagnosis of acute phase but did not improve the evaluation of comparative postnatal profile. Althougth few infants have concluded the postnatal follow-up, the preliminary results showed a greater value of using a IgM and IgA WB test than other standard method for the early diagnosis of toxoplasmosis at birth also in child born to treated mothers. The comparative anti-T gondii IgG immunoblot profile of mother and child permitted us to reduce the time of ruling out infection in newborns born to mothers with probable or possible infection and/or when prenatal diagnosis is negative or not performed.

Viral gastroenteritis in children hospitalised in Sicily, Italy

The aim of the present study was to describe the epidemiologic and clinical characteristics of acute viral gastroenteritis in hospitalised Italian children. A total of 215 stool specimens were collected from January to December 2003 from patients hospitalised in Palermo for acute diarrhoea. Samples were tested for group A rotavirus, astrovirus, adenovirus, norovirus, enteropathogenic bacteria, and parasites. Rotaviruses, mostly belonging to types G1-G4, were detected in 25.1% of samples, astrovirus in 7%, adenovirus in 6%, norovirus in 18.6%, and bacterial agents in 17.2%. No parasitic infections were diagnosed. Mixed infections represented 9.8% of all cases. The mean and median ages of children with rotavirus gastroenteritis were lower than those of children with other viruses (p = 0.029), with the highest median ages being found in astrovirus-infected patients. Vomiting and dehydration were more frequent among patients with viral infection (p < 0.01), and the severity score was significantly higher for children infected with astrovirus or group A rotavirus (p = 0.008). Rotavirus was the leading cause of prolonged hospitalisation (p = 0.005). In conclusion, viruses were confirmed in Italy as the most common cause of severe enteric illness in childhood, with rotavirus types G1-G4, which correspond to those included in the rotavirus vaccines being developed, playing the main role. Routine testing should be introduced for noroviruses, since they seem to represent an important cause of sporadic paediatric gastroenteritis.

Hormonal, auxological and clinical follow-up in children with connatal HIV infection. Personal records

AIM

HIV infection and antiretroviral drugs have relevant endocrine implications, affecting growth and pubertal development. Moreover stature impairment cannot depend only on decreased hormonal secretion.

METHODS

We studied for 7 years growth, puberty, bone maturation, hormonal secretion [Growth Hormone (GH) basal and after stimulation with Clonidin and Insulin, Insulin-like Growth Factor 1 (IGF-1), Insulin-like Growth Factor Binding Protein 3 (IGFBP-3), FSH, LH- gonadic hormones axis, ACTH, Cortisol, TSH, fT4, T4, T3, anti-thyroid antibodies, Leptin] of 10 HIV-infected children.

RESULTS

In 3 patients stature was <-2 SDS in the first 2 years and in prepubertal age, with intervals of improved growth. The weight was >2 SDS in 6 children, <-2 SDS in 1 girl, while the other 3 patients had a weight <-2SDS only in the first 2 years of life. Height growth velocity was >10 degrees Centile all over the years of follow-up in 9 patients, while weight growth velocity was pathological in 5. Leptinemia showed higher levels at the beginning of follow up: 0.82-11.68 ng/L (M+/-DS: 3.29+/-4.15) than at the end of the study: 0.2-3 ng/L (M+/-DS: 1.65+/-1.01). Leptin levels showed a statistically significant correlation with CD4/CD8 count (P: 0.010; r: 0.916) and with the CDC stage (P: 0.006; r: 0.937), meaning a strong link to the severity of the disease.

CONCLUSIONS

A good clinical control of HIV infection can guarantee growth within physiological centile in most of HIV-infected children. Over all IGFBP-3 and IGF-1 are good markers of growth, more usable than GH.

[Urinary schistosomiasis: remarks on a case]

Urinary tract schistosomiasis is a parasitic disease caused by S. haematobium with a wide range of clinical manifestations related to the mucosal and submucosal granulomatous lesions of the bladder. It affects about 80 million people in Africa, Middle-East and India, while in Italy it is rarely seen among immigrants from endemic areas and returning travellers. The authors describe a case occurred in a 26 years old man, recently emigrated from a rural area of Ghana. He had the symptoms of a haemorrhagic cystitis. Cystoscopy and biopsy showed granulomatous lesions of bladder with calcified eggs. Microscopic examination of urine was positive for Schistosoma haematobium eggs. The therapy with Praziquantel (40 mg/Kg una tantum) was effective. The authors emphasized the risk of introduction of schistosomiasis in some regions of our country, in consideration of the presence of the intermediate host as well as of an appropriate climate.

[Pulmonary infection caused by Blastoschizomices capitatus]

Geotrichum capitatum, now known as Blastoschizomyces capitatus, can be responsible for several opportunistic infections (systemic infection or localized at lungs, liver, kidney, encephalitis or meningitis) in an immunocompromised host, especially in those patients affected by leukaemia or under immunosuppressive therapies. A 66-year-old woman with polimyosite under steroid and immunosuppressant therapy was hospitalized in ICU for an acute respiratory distress with moderate hypoxaemia and normocapnia. Pulmonary X-ray revealed a bilateral pneumonia. Hypoxaemia became severe 48 hours later and the patient underwent mechanical ventilation and empirical antibiotic therapy. Blood cultures, urine cultures and serological tests were negative, while yeast was identified by Gram's stain of bronchoaspirate. Before identifying the yeasts Fluconazole was added to therapy. At day 5 the clinical conditions remained severe and Candida spp were excluded: so Fluconazole was switched to liposomal Amphotericin B. At day 8 B. capitatus was identified. At day 26 the patient died of refractory respiratory insufficiency. B. capitatus infection is infrequent and its prognosis is severe, with a high mortality rate (>50%). Microbiological diagnosis requires time to characterize the yeast. At present no standard therapy is available although some authors report a good susceptibility to Amphotericin B and Voriconazole (100%), according to NCCLS guidelines.

Tuberculosis of the central nervous system in children: 32 years survey

AIM

In order to study the impact of clinical and diagnostic parameters on the clinical outcome of children with central nervous system tuberculosis (CNS-TB), we retrospectively reviewed all cases of CNS-TB diagnosed over a 32-year period at the Children's Hospital of Palermo, Italy.

METHODS

Data were collected with regard to the clinical, laboratory and demographic characteristics of patients, as well as the results of radiological investigations and data on clinical outcome. In relation to the date of introduction of new diagnostic methods (indirect as well direct) and to the change of treatment periods, the authors compared the clinical outcome of patients admitted prior and after 1984. They also classified the patients into 3 different stages of illness according to the severity of the disease on admission.

RESULTS

We identified 80 patients with CNS-TB. The mean age of the children was 3 years with 54% of patients younger than 5 years. The contact source was documented in 40 patients (50%). The mean duration of symptoms prior to admission was 22 days (range 5 days - 3 months). Mantoux skin test was positive on admission in 50 patients (62%). CSF smear microscopy and culture were positive in 29% and 45% of patients respectively. PCR for Mycobacterium tuberculosis introduced in 1994 was positive in 11 out of 13 tested patients. Determination of CSF gdT lymphocytes composition applied in 7 patients shows a predominance of Vg9/Vd2 T lymphocytes. Fifteen subjects (19%) died; 11 (13%) suffered from permanent sequelae. The died children and those with permanent sequelae were younger than the others (p<0.05). Prior to 1984, none of the patients were identified during early stage of illness and 4 out of 37 patients with stage II illness died. After 1985, 44% of children were in stage I and 2 out of 4 patients with stage III died (p<0.05).

CONCLUSIONS

Stage of disease and young age are still the decisive factors in the clinical outcome of children with CNS-TB. The availability of new advanced methods has improved the identification of patients with CNS-TB in stage I and therefore the possibility of an early treatment of such patients.

Pulmonary tuberculosis in Italian children by age at presentation

AIM

To evaluate the clinical characteristics, diagnostic methods and outcome of paediatric pulmonary tuberculosis (PTB) in relation to children's ages when observed.

METHODS

Children under 15, who had been admitted to the Children's Hospital with PTB were prospectively evaluated. Our sample included patients with a positive tuberculin skin test and signs or symptoms of tuberculosis (TB), including abnormal chest X-rays which suggested PTB. We collected demographic, clinical, radiographic and microbiological data from the patients, in addition to carrying out contact investigations in order to find a source case. All the patients involved in this study were subjected to anti-tuberculosis treatment.

RESULTS

Sixty-two patients (44% under 5) were eligible for inclusion in our study. Children with presenting symptoms were younger than asymptomatic patients (p<0.05). A source case was found in 38 patients out of 62 children (62%) and children under 5 were more likely to have a source case than that found with older children (p<0.05). Ghon complex (infiltrate + adenopathy) tended to occur in young children (median age of 3.25, p<0.05). Fourteen children (23%) had clinical specimens which tested positive for Mycobacterium tuberculosis (MT), and 20 (32%) for MT DNA according to a polymerase chain reaction (PCR). Resistant strains to 1 or more anti-tuberculosis drugs were found in 5 children and in 4 adult sources. The patients with minimal or no radiographic change during therapy displayed symptoms for a longer period of time and were infected by a resistant strain (p<0.05).

CONCLUSION

Improvements in case detection, case management and contact investigations are necessary for controlling paediatric TB, especially in young children. Given that any diagnosis of TB in children is supported by epidemiological and clinical evidence rather than isolating MT, detection of the source case is important in selecting appropriate treatment.

Monocyte and lymphocyte apoptosis resistance in acute and chronic brucellosis and its possible implications in clinical management

This study evaluated the level of susceptibility of monocytes and lymphocytes to spontaneously induced and CH11-induced apoptosis in 16 patients with Brucella infection. The expression of some immunological and apoptotic markers was evaluated. Before therapy, monocytes showed a high level of resistance to spontaneously induced or CH11-induced apoptosis in all patients. In patients with acute infection, this resistance persisted for 10-20 days after treatment was initiated, then decreased; in chronically infected patients, it persisted after 45 days of treatment. Lymphocytes were also more resistant to CH11-induced apoptosis. The level of activated CD8(+) T lymphocytes was high in patients with acute infection. The data indicate that the CD95-mediated apoptotic pathway is not involved in CH11 resistance. Lymphocytes are not infected by Brucella, so their resistance to apoptosis may be due to a soluble factor released by infected monocytes. The evaluation of levels of susceptibility to CH11-induced apoptosis in monocytes may be used to test the effectiveness of the therapy.

Treatment of human brucellosis with rifampin plus minocycline

In order to evaluate the efficacy and tolerability of a high intravenous dose of rifampin plus oral minocycline (administered daily for 3 weeks) for the treatment of acute brucellosis, we retrospectively reviewed the outcome of 239 consecutive patients (135 adults and 104 children) diagnosed and treated over a 17-year period in Italy. The combination used resulted in 100% response and a relapse rate lower than 2%. Fifty-two (30 adults and 22 children) (29.8%) complained of mild adverse effects including an increase in aspartate aminotransferase (>250 IU) observed in 12 cases and considered related to rifampin and in 11 cases a reversible hyperpigmentation of the tongue attributed to minocycline. A randomized prospective comparative study should be performed to confirm our encouraging results.

Serum leptin and interleukin-6 levels in pediatric patients with HIV

Recent therapeutic approaches have improved the prognosis of children with HIV. Many new efforts could be involved in their quality of life and therefore could need additional diagnostic strategies. Leptin regulates pubertal development; furthermore a continuous immune stimulus, as in chronic infectious diseases, can enhance leptin's secretion by the action of cytokines such as interleukin (IL)-6. To clarify this role in patients infected with HIV, we assayed leptin and IL-6 and evaluated the influence of HIV severity on its secretion. IL-6 (380.5 +/- 257.6 pg/ml; range: 22-900 pg/ml) showed a significant correlation with leptinemia, HIV-1 RNA, and viremia related to the stage of HIV disease. The difference in leptinemia from a control group (3 +/- 3.2 ng/ml; range: 1-12 ng/ml in HIV patients; 6.72 +/- 8 ng/ml in the controls) did not reach statistical significance, nor did it correlate with pubertal stage, BMI, viremia, CD4 or anti-retroviral therapy. There was a statistically significant correlation between leptinemia and the stage of the HIV disease, and with IL-6 level. We want to stress the role of immunological factors in enhancing leptin secretion.

Pediatric visceral leishmaniasis in Western Sicily, Italy: a retrospective analysis of 111 cases

The clinical and epidemiological characteristics of 111 consecutive cases of visceral leishmaniasis identified from 1980 to 2000 in a Sicilian pediatric hospital were analyzed retrospectively. The mean age of the patients was 1.7 years. All children were HIV negative, but 15% were severely malnourished. Fever and splenomegaly were present in all cases and hepatomegaly in 101 (90.1%) cases. Thrombocytopenia and anemia were both observed in 78 (70.2%) cases and leukopenia in 47 (42.3%) cases. A bone marrow aspirate was obtained in all cases; Leishmania amastigotes were detected in 89 (80.2%) cases. Initial treatment consisted of meglumine antimoniate in 99 (89.2%) patients and amphotericin B in 12 (10.8%) patients. Only two children treated with meglumine antimoniate relapsed. The findings highlight the differences between the cases of visceral leishmaniasis observed in the Mediterranean basin and those observed in other regions. The use of the term "Mediterranean visceral leishmaniasis", rather than the term "kala-azar", is proposed for cases observed in the Mediterranean area.

Efficacy and safety of clarithromycin as treatment for Mediterranean spotted fever in children: a randomized controlled trial

Fifty-one children with Mediterranean spotted fever (MSF) were randomized to receive either clarithromycin, 15 mg/kg/day orally in 2 divided doses, or chloramphenicol, 50 mg/kg/day orally in 4 divided doses, for 7 days. Mean time to defervescence was 36.7 h in the clarithromycin group and 47.1 h in the chloramphenicol group (P=.047). Clarithromycin could be an acceptable therapeutic alternative to chloramphenicol and to tetracyclines for children aged <8 years with MSF.

Change of Th0 to Th1 cell-cytokine profile following tuberculosis chemotherapy

T cells mediate protection against tuberculosis, but little is known about their role during chemotherapy of patients with active disease. Here we examined the cytokine profile of CD4 T cells before and after four months of chemotherapy in six initial skin test anergic cases. Purified protein derivative (PPD) and 16-kDa antigen-reactive CD4 T-cell clones prior to therapy resided mostly in disease-associated body fluids and were of the Th0 (interferon (IFN)-gamma + interleukin (IL)-4) secreting profile. In contrast, the majority of postchemotherapy CD4 T-cell clones originated from blood and were of the IFN-gamma secreting Th1 type. However, the recognition of several peptides derived from the 16-kDa antigen was not significantly different between the Th1 and Th0 clones. We conclude that chemotherapy shifts CD4 T cells from the affected body fluids to the blood circulation, accompanied by a change from Th0 to Th1 cytokine profile.

Ligand-specific alphabeta and gammadelta T cell responses in childhood tuberculosis

The alphabeta and gammadelta T cell responses were analyzed in the peripheral blood of children affected by active tuberculosis (TB) and in healthy children who tested positive (PPD+) or negative (PPD-) for purified protein derivative. PPD+ healthy and diseased children responded equally well to PPD in vitro. In contrast, only 18% of PPD+ TB patients responded to peptide p38G derived from the 38-kDa protein of Mycobacterium tuberculosis. Analysis of the whole gammadelta T cell population and of its Vgamma9/Vdelta2 subset showed similar frequencies in PPD+ children with TB and in healthy PPD+ and PPD- children. Vgamma9/Vdelta2 cells from children with TB responded to 5 different phosphoantigens similarly to those from healthy PPD+ children, but healthy PPD- children responded very poorly. Chemotherapy had contrasting effects on the tested lymphocyte population, represented by increase of alphabeta and decline of Vgamma9/Vdelta2 T cell responses. T cell responses in childhood TB may be similar to those in adult TB.

Sequestration of T lymphocytes to body fluids in tuberculosis: reversal of anergy following chemotherapy

The specificity of CD4 T lymphocytes was investigated in 6 patients affected by tuberculosis who had negative tuberculin purified protein derivative (PPD) skin tests at diagnosis. Polyclonal CD4 T cell lines from the peripheral blood failed to proliferate to PPD and to the 16- or 38-kDa proteins of Mycobacterium tuberculosis, while CD4 cell lines from the disease site responded to PPD and to the 16- and 38-kDa proteins and derived epitopes in vitro. Four months after chemotherapy, the patients became responsive to PPD. The proliferative response to PPD and to the 16- or 38-kDa proteins and their derived peptides decreased in CD4 T cell lines from the disease site and increased in lines from the peripheral blood. These results indicate that CD4 T cells recognizing a vast array of M. tuberculosis epitopes are compartmentalized at the site of disease in anergic patients but appear in peripheral blood after chemotherapy.

Clinical and laboratory findings of boutonneuse fever in Sicilian children

The spectrum of signs and symptoms of 645 consecutive children diagnosed from 1984 to 1996 with boutonneuse fever (BF), a mild rickettsial disease caused by Rickettsia conorii endemic in the Mediterranean basin, are reported. The major clinical features were fever (97.2%), exanthema (96.1%) and "tache noire" (71.8%). The large series examined permitted the authors to observe some rare or disregarded clinical features of the disease: cases with papulovesicular exanthema, reported previously only in adults who had been infected by R. conorii in Africa; and cases in which the only symptom was an isolated lymphadenopathy.

CONCLUSION

R. conorii infection should be considered in patients with lymphadenopathy who live in or have travelled to an endemic area, even when other, more specific features, are not present. Also pox-like vesicular lesions may be caused by this organism, awaiting confirmation by using culture techniques instead of serology. The serological confirmation of BF by immuno fluorescent antibody test is possible only late in the illness.

[Descriptive analysis of measles epidemic in Palermo, from September 1996 to June 1997. Failure of a vaccination campaign]

BACKGROUND

The authors report 1642 measles cases observed from September 1996 to June 1997 at the "G. Di Cristina" Children's Hospital. 34% of patients were hospitalized at the Division of Infectious Diseases.

METHODS

The records of children admitted with measles to emergency area were retrospectively collected. The medical records (anamnestic, clinical and laboratory findings) of hospitalized children were obtained from schedules which since 1993 were performed to perspectively collect the exanthematous diseases. International criteria for the definition of measles case were applied. The variables considered were: background, demographic data, seasonal distribution, clinical presentation, complications and days of hospital stay.

RESULTS

The results of this research showed that the outbreak involved predominantly infants. The complications accounted for 72% of measles hospitalized cases. Four cases of encephalitis were observed. A total of 1692 days of hospital stay was reported.

CONCLUSIONS

These data show the failure in measles control adopted by the Sicilian Region and confirm the difficulties to achieve high percentage of parents participation to the infant recommended vaccination program.

Epidemiologic surveillance of visceral leishmaniasis in Sicily, Italy

Visceral leishmaniasis (VL) is endemic in Sicily. Although it is a notifiable disease, there is evidence that the actual number of cases is higher than that reported. In 1987, a regional reference center for active surveillance of VL was established and it recorded a total of 284 cases through 1995, a mean of 31.5 cases/year and about four-fold more than previously reported. Of the 284 cases, 150 (53%) were children (< or = 14 years of age), and of the 134 adults, 39 (29%) were coinfected with human immunodeficiency virus (HIV). The commonest viscerotropic zymodeme of Leishmania infantum, MON 1, was identified in 40 (93%) of 43 HIV-negative and eight (57%) of 14 HIV-positive patients. Among 280 patients evaluated (i.e., all HIV-negative and 35 of 39 HIV-positive subjects), 254 (91%) were treated with meglumine antimoniate alone or in combination with other drugs; 23 (8%) received allopurinol or amphotericin B, either conventional or in liposomal form; and three terminally ill patients were not treated. Among the 245 HIV-negative patients, 236 (96%) were successfully cured, while nine (4%) (seven adults) died during the course of antimonial treatment. None of the 35 HIV-positive patients was definitively cured, although mortality was apparently associated with other opportunistic infections.

Chickenpox complications among immunocompetent hospitalized children in Italy. Acyclovir-Chickenpox Italian Study Group

OBJECTIVE

To evaluate the frequency and clinical spectrum of chickenpox complications among immunocompetent hospitalized children.

PATIENTS AND METHODS

Multicentre retrospective study of clinical records of all patients consecutively hospitalized for varicella during the last decade, in ten tertiary care clinical centres of Pediatrics and Infectious Diseases, throughout Italy.

RESULTS

Two hundred and nineteen out of 991 patients (22.1%) hospitalized for varicella suffered from a complicated disease (247 complicating events on the whole). Central nervous system (CNS) involvement was prevalent (104 episodes), followed by skin/soft tissue infections, lower respiratory tract involvement, and thrombocytopenia. A complicated disease was significantly associated with the male gender and an elevated incidence of varicella-zoster (VZ) virus infection acquired by household contacts. The involvement of lower respiratory airways and skin/soft tissues seemed to occur at an earlier age, compared with CNS and thrombocytopenia. Moreover, lower respiratory tract and skin/soft tissue infections occurred earlier during disease course than complications interesting the CNS and coagulation system. All subjects with complicated chickenpox showed a favourable outcome within 5-40 days, except two patients developing a lethal cardiomyopathy and Reye syndrome, respectively. Anyway, chickenpox complications led to a prolonged hospitalization, and needed further pharmacologic treatment in all evaluated cases. The administration of anti-VZ virus treatments (i.v. acyclovir or VZ immunoglobulins) did not modify significantly the course of disease in treated patients, when compared with untreated ones.

CONCLUSIONS

Although chickenpox is considered a self-limiting, uncomplicated disease in immunocompetent children, when assessing hospitalized patients a considerable incidence and a broad spectrum of complications are observed, requiring prolonged admission and pharmacologic and supportive care. Even though a lethal outcome remains a rare occurrence, it may be of relevant concern when considering the overall incidence of chickenpox in the general population. The role of an early antiviral treatment in reducing the incidence and severity of varicella complications deserves further evaluation.

[Tuberculous meningo-encephalitis in pediatrics. Considerations on 71 cases (1968-1993)]

The tuberculous meningitis is an uncommon but severe complication of the tuberculosis mainly in childhood. Neurological sequelae are frequent and high mortality rate, till now, occurs. We reviewed the medical records of 71 cases and we evaluated the most frequent symptoms before the admission and signs and symptoms on the admission according to prognosis. An early diagnosis and specific anti-tuberculous treatment are essential in order to prevent permanent neurological sequelae and fatal outcome

Effect of priming with diphtheria and tetanus toxoids combined with whole-cell pertussis vaccine or with acellular pertussis vaccine on the safety and immunogenicity of a booster dose of an acellular pertussis vaccine containing a genetically inactivated pertussis toxin in fifteen- to twenty-one-month-old children. Italian Multicenter Group for the Study of Recombinant Acellular Pertussis Vaccine

OBJECTIVE

To evaluate the safety and the immunogenicity of a booster dose of recombinant acellular pertussis vaccine combined with diphtheria and tetanus toxoids (DTaP, Biocine SpA) in 15- to 21-month-old children primed in infancy with either whole-cell diphtheria-tetanus-pertussis (DTwP) vaccine or DTaP vaccine.

DESIGN

Open-label second phase of a double-masked, controlled trail, with masked analysis of serum samples.

PARTICIPANTS AND SETTING

Three hundred fifty children, 15 to 21 months of age, who had been primed at 2, 4, and 6 months of age with either three doses of DTaP vaccine (n = 173) or DTwP vaccine (n = 177). The children were enrolled in eight vaccination centers in Italy.

INTERVENTIONS

All children received a booster dose of the DTaP vaccine and were examined for safety at 48 hours and at 7 days after vaccination. Serum samples for evaluation of immunogenicity were obtained from 196 (55%) of the 350 children.

MAIN OUTCOME MEASURES

IgG antibodies to pertussis toxin (Ptox), filamentous hemagglutinin, 69-kilodalton protein, and tetanus toxoid were measured by enzyme-linked immunosorbent assay. Pertussis toxin-neutralizing antibodies were measured by the Chinese hamster ovary cell toxin neutralization assay.

MAIN RESULTS

Adverse reactions to DTaP were infrequent, and there was no difference in the incidence of local or systemic reactions in children given DTaP as a fourth dose in comparison with a first dose. One month after the DTaP booster vaccination, both groups had 6- to 40-fold increases in serum antibody concentrations to all antigens tested; the concentrations against the three pertussis antigens were higher in the DTaP-primed children (p < 0.05). The antibody titers to diphtheria and tetanus toxoids were higher in the DTwP-primed group (p < 0.05), but both groups had protective titers. The geometric mean ratio of anti-Ptox neutralizing antibody per unit of IgG anti-Ptox antibody was higher in the DTaP-primed group (p < 0.001).

CONCLUSIONS

There are quantitative and qualitative differences in booster responses to DTaP vaccine in young children, depending on whether they were given DTaP or DTwP as primary immunization. This DTaP vaccine is safe and highly immunogenic as a booster.

[Not Available]

In June 1994 have been seen 16 patients with HPV B19 infection. The diagnosis was based on a positive E.L.I.S.A. test for IgM antibodies against HPV B19. No one of the patients had hematologic manifestations. Only one patient had fever, arthralgia and headache without skin involvement. The other 15 patients had skin lesion: rubella like rush in 11 cases, haemorragic exanthema in 2 and erythema infectious in 2 cases. Two children had liver involvement and one kidney involvement. The authors of this study remark the broad spectrum of clinical manifestations of HBV B19 infection and suppose a large diffusion of this disease, even in the symptomatic form.

Retrospective survey on the epidemiology of H. influenzae type B meningitis in Italy (1987-91)

A retrospective survey on the epidemiology of H. Influenzae type b (Hib) meningitis was carried out in seven Italian hospitals. During the period 1987-1991, 95 (16.3%) Hib meningitis cases out of 581 bacterial meningitis cases were observed. The proportion of Hib meningitis was lowest in 1987 (11.3%); elevated in 1988 (17.9%); thereafter it did not change. A male preponderance was observed (Sex ratio 1.6). The age distribution showed that 93.7% of cases occurred in subjects < 5 years, 53.7% of cases in those < 1 year. Although Hib meningitis accounts for a small proportion of all bacterial meningitis, it is also a major problem in Italy in early childhood, because nearly all cases occur in children < 5 years.

Comparative study of a whole-cell pertussis vaccine and a recombinant acellular pertussis vaccine. The Italian Multicenter Group for the Study of Recombinant Acellular Pertussis Vaccine

The safety and immunogenicity of an acellular pertussis vaccine containing the genetically detoxified pertussis toxin PT-9K/129G, filamentous hemagglutinin, and pertactin, together with diphtheria and tetanus toxoids, were compared with those of a whole-cell pertussis component-diphtheria-tetanus vaccine. Four hundred eighty infants were enrolled into this prospective, multicenter, double-blind study. Each infant was randomly given three doses of one of the two vaccines at 2, 4, and 6 months of age. Both local and systemic adverse reactions, reported within 48 hours and 7 days of each injection, were less frequent after the acellular vaccine than after the whole-cell vaccine. The enzyme-linked immunosorbent assay titers to pertussis toxin, filamentous hemagglutinin, and pertactin, as well as the pertussis toxin-neutralizing titer measured by the Chinese hamster ovary cell assay, were significantly higher after the acellular vaccine was given. Both vaccines induced adequate levels of anti-diphtheria and anti-tetanus antibodies. We conclude that the recombinant acellular pertussis vaccine produces fewer reactions than the whole-cell vaccine and provides a high antibody response against the antigens of Bordetella pertussis involved in bacterial adhesion and systemic toxic effects.

Immunogenicity of an acellular pertussis vaccine composed of genetically inactivated pertussis toxin combined with filamentous hemagglutinin and pertactin in infants and children

We studied the immunogenicity of an acellular pertussis vaccine composed of genetically detoxified pertussis toxin (PT-9K/129G), filamentous haemagglutinin, and a 69-kilodalton protein, pertactin, in 30 children aged 12 to 24 months and in 80 infants aged 2 to 4 months. A significant increase of the neutralizing titer and of the titers against pertussis toxin, filamentous hemagglutinin, and pertactin, as determined by enzyme-linked immunosorbent assay, was achieved after three doses of vaccine in all the children; a significant increase of these antibody titers was obtained in 100%, 96.1%, 93.5%, and 98.7% of the infants, respectively.

Acellular pertussis vaccine composed of genetically inactivated pertussis toxin: safety and immunogenicity in 12- to 24- and 2- to 4-month-old children

To determine whether a nontoxic derivative of pertussis toxin obtained by recombinant DNA technology, PT-9K/129G, is a good candidate for a new pertussis vaccine, we examined the safety and the immunogenicity in children of a vaccine containing 15 micrograms of PT-9K/129G protein and 0.5 mg of aluminum hydroxide per dose. Fifty-three children 12 to 24 months of age and 21 infants aged 2 to 4 months were injected with two and three doses, respectively. The vaccine did not induce significant local or systemic reactions and elicited an increase of antibody titer in more than 98% of the children. The geometric mean of the toxin-neutralizing titers increased after each dose and was 85 units in children given two doses and 196 units in those given three doses. Two children who had detectable antibody levels before the first immunization had a high response (greater than 320 units) to the first vaccine dose. The findings suggest that PT-9K/129G is a promising antigen to be included in the development of acellular pertussis vaccines.

Comparison of serological methods for the detection of IgG and IgM antibodies to rubella virus

Four commercial kits- the hemagglutination inhibition test Behring (HI-B), the HI Rubenosticon, the latex test Rubalex, the enzyme-linked immunosorbent assay (ELISA) ETI-RUBEK G--and a non-commercial hemolysis test in gel (SRH) were compared for the measurement of rubella IgG antibodies by testing 126 serum samples, submitted for rubella immune status determination. Two commercial ELISAs (ETI-RUBEK M and Rubazyme M) were also evaluated for the detection of rubella IgM antibodies on 64 sera from patients with suspected acute rubella infection. In the assay for rubella specific IgG antibodies, HI-B and ETI-RUBEK G tests exhibited the most sensitivity, whereas Rubenosticon and Rubalex tests showed more specificity. In the IgM evaluations, six false positive results were shown by Rubazyme M, whereas the ETI-RUBEK M kit was sensitive and specific. On the basis of all the determinations, a combination of two tests (HI-B and SRH) appears to be a good simple system to obtain valid indications in serological rubella diagnosis.

Electropherotyping of human rotaviruses: an epidemiological survey of rotavirus infections in Sicily

An electrophoretic analysis of rotavirus RNA segments was carried out on 522 faecal specimens, obtained from children hospitalized in Sicily in the period 1981/85. One hundred and one viral isolates could be characterized with respect to the electrophoretic pattern of their genomic RNAs. This analysis revealed that in 1981/82 different electropherotypes cocirculated in the infant population. In 1983 one of the patterns became prevalent; in 1984/85 only one electropherotype was detected, both in Palermo and Catania specimens. The serotyping showed that all viral strains with the prevalent electropherotype were subgroup II and serotype 1. These results contrast with the extensive genome variability of rotavirus strains observed in urban areas.

[Virological and serological study in the herpetic gengivostomatitis (author's transl)]

Virological and serological investigations to verify herpetic etiology have been performed on 24 children and 1 adult with acute gengivostomatitis. Viral isolation and detection of antibodies against HSV, carried out by neutralization, complement fixation, and indirect immunofluorescence techniques, have confirmed this etiology in the 88% of cases.