Human CD8 T lymphocytes recognize Mycobacterium tuberculosis antigens presented by HLA-E during active tuberculosis and express type 2 cytokines

CD8 T cells contribute to protective immunity against Mycobacterium tuberculosis. In humans, M. tuberculosis reactive CD8 T cells typically recognize peptides associated to classical MHC class Ia molecules, but little information is available on CD8 T cells recognizing M. tuberculosis Ags presented by nonclassical MHC class Ib molecules. We show here that CD8 T cells from tuberculosis (TB) patients recognize HLA-E-binding M. tuberculosis peptides in a CD3/TCR αβ mediated and CD8-dependent manner, and represent an additional type of effector cells playing a role in immune response to M. tuberculosis during active infection. HLA-E-restricted recognition of M. tuberculosis peptides is detectable by a significant enhanced ex vivo frequency of tetramer-specific circulating CD8 T cells during active TB. These CD8 T cells produce type 2 cytokines upon antigenic in vitro stimulation, help B cells for Ab production, and mediate limited TRAIL-dependent cytolytic and microbicidal activity toward M. tuberculosis infected target cells. Our results, together with the finding that HLA-E/M. tuberculosis peptide specific CD8 T cells are detected in TB patients with or without HIV coinfection, suggest that this is a new human T-cell population that participates in immune response in TB.

Disseminated tuberculosis in a patient treated with a JAK2 selective inhibitor: a case report

Background

Primary myelofibrosis is a myeloproliferative disorder characterized by bone marrow fibrosis, abnormal cytokine expression, splenomegaly and anemia. The activation of JAK2 and the increased levels of circulating proinflammatory cytokines seem to play an important role in the pathogenesis of myelofibrosis. Novel therapeutic agents targeting JAKs have been developed for the treatment of myeloproliferative disorders. Ruxolitinib (INCB018424) is the most recent among them.

Case presentation

To our knowledge, there is no evidence from clinical trials of an increased risk of tuberculosis during treatment with JAK inhibitors. Here we describe the first case of tuberculosis in a patient treated with Ruxolitinib, a male with a 12-year history of chronic idiopathic myelofibrosis admitted to our Institute because of fever, night sweats, weight loss and an enlarging mass in the left inguinal area for two months.

Conclusion

Treatment with Ruxolitinib may have triggered the reactivation of latent tuberculosis because of an inhibition of Th1 response. Our case highlights the importance of an accurate screening for latent tuberculosis before starting an anti-JAK 2 treatment.

Probable disseminated Mycobacterium abscessus subspecies bolletii infection in a patient with idiopathic CD4+ T lymphocytopenia: a case report

Introduction

Rapidly growing mycobacteria are opportunistic pathogens in patients with underlying risk factors. Mycobacterium abscessus subsp. bolletii is a newly recognized member of rapidly growing mycobacteria, isolated from respiratory tract and cutaneous infections.

Case presentation

We describe a case of chronic disseminated infection caused by M. abscessus subsp. bolletii in a 38-year-old Sri Lankan man with idiopathic CD4+ T lymphocytopenia. Idiopathic CD4+ T lymphocytopenia is a rare cause of immunodysfunction that, similar to human immunodeficiency virus infection, causes a depletion of CD4+ T lymphocytes. M. abscessus subsp. bolletii infection was diagnosed by culture isolation from two sputum samples.

Conclusions

To the best of our knowledge this is the first report of M. abscessus subsp. bolletii disseminated infection in a patient affected by idiopathic CD4+ T lymphocytopenia. In contrast to previous reports, the isolate of M. abscessus subsp. bolletii presented intermediate resistance to clarithromycin and was susceptible to cefoxitin and imipenem.

[Leprosy-like cutaneous presentation of Histoplasma capsulatum infection in an African HIV+ patient]

Histoplasma capsulatum is an opportunistic dimorphic fungus responsible for most often self-limiting or flu-like infections but potentially lethal in immunocompromised hosts. Histoplasmosis is rare in Europe. We reported a case of disseminated histoplasmosis in an African HIV patient with a leprosy-like primary cutaneous presentation and involvement of lungs, brain, limphnodes and eye. The therapy with liposomial B amphotericin and itraconazole led to a prompt resolution of the symptoms.

Prevalence of Toscana sandfly fever virus antibodies in neurological patients and control subjects in Sicily

Toscana sandfly fever virus (TOSV) is an arthropod-borne virus transmitted to humans by sandfly vectors. It has been associated with human cases of meningitis and meningo-encephalitis mainly occurring during the warm season. We performed a retrospective serological study to evaluate TOSV circulation in Palermo, Sicily, and to compare TOSV seroprevalence in patients with neurological symptoms and in a control group of patients without neurological symptoms. When sera from 155 patients with and without neurological symptoms were evaluated, the rate of overall TOSV IgG reactivity was 17.4%. Patients with neurological symptoms showed a higher percentage of TOSV IgG positivity than control patients (25% versus 10.8%). TOSV exposure was confirmed by virus neutralization tests which also detected a Naples virus (SFNV) infection. TOSV should be considered as an etiologic agent in the differential diagnosis of fever and meningo-encephalitis in Sicily.

[Cytomegalovirus infection in immunocompetent patients. Clinical and immunological considerations]

Cytomegalovirus primary infection is considered dangerous for some kinds of patients: immunocompromised (HIV-infected and transplanted patients), newborns with congenital infection, and immunocompetent patients in critical condition. CMV infection is usually asymptomatic or only mildly symptomatic in immunocompetent hosts. We collected all cases of acute CMV infection that came to our attention during the period November 2009 - May 2011 to analyze their clinical features. Immunoenzymatic methods (ELISA) were used for the detection of specific IgM and IgG antibodies in every case. We observed 73 cases of acute CMV infection. The male-female ratio was 1.5/1. The average age was 36.4. All the patients had fever, 16 (22%) pharyngitis, only 9 (12.3%) lymphadenopathy. The most common complications were hepatitis, encephalitis, pericarditis and pneumonia. Unknown genetic factors may greatly influence the clinical expression of the illness.

[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.

Lymphocyte apoptosis in children with central nervous system tuberculosis: a case control study

Background

Studies of the apoptosis mechanisms involved in the pathogenesis of tuberculosis have suggested that Mycobacterium tuberculosis can actively interfere with the apoptosis of infected cells. In vivo studies have been performed in adult populations but have not focused on this process in children. In the present study, we analyzed spontaneous T lymphocyte (PBT) apoptosis in the peripheral blood of children with central nervous system tuberculosis (CNS TB), before and after chemotherapy, and compared the results with healthy controls.

Methods

A case-control study was conducted from January 2002 to June 2009. It included 18 children with CNS TB and 17 healthy controls. Spontaneous apoptosis of PBTs, including CD4⁺, CD8⁺ and CD8⁺/CD28⁺ T cells, was evaluated after 24 and 72 h of culture in complete medium, using the Annexin V detection test. Analysis was conducted before and after chemotherapy, and expression of the apoptotic markers CD95 (Fas) and Fas ligand (FasL) was evaluated.

Results

Higher percentages of apoptotic T cells and CD4 lymphocytes were isolated from children with acute phase CNS TB than from children in the control group (p < 0.05). This difference significantly decreased after 60 days of specific treatment. In children with CNS TB, high levels of Fas ligand expression were detected in lymphocyte populations, associated with a high percentage of Fas positive cells, before and after treatment. In contrast to the CD4+ apoptosis profile, we did not find any significant difference in total CD8⁺ cell apoptosis between children with acute phase disease and the control group. However, the percentage of apoptotic CD8⁺/CD28⁺ T cells was significantly higher in the children with acute phase disease than in the healthy controls.

Conclusions

Our findings indicate that CNS TB in pediatric patients increases the sensitivity of CD4 and CD8⁺/CD28⁺ T cells to apoptosis, suggesting a hypoergic status of this infection. This could play a key role in the immunopathogenesis of this complicated form of TB. Interestingly, specific chemotherapy is able to normalize both apoptosis sensitivity and T-cell activation.

Investigation and management of Toxoplasma gondii infection in pregnancy and infancy: a prospective study

AIM

Toxoplasma gondii infection during pregnancy poses a serious risk to the fetus, therefore timely and accurate diagnosis is essential. The aim of this study was to estimate the frequency of congenital infection via evaluating mother's immunological status and the possibility to improving the diagnostic and therapeutic approaches.

METHODS

Eighty five mothers with Toxoplasma seroconversion and their offspring were enrolled (among them, 2 spontaneous abortions were documented in the first trimester). Prenatal PCR diagnosis was carried out on 50 patients (60%), with 7 positive cases (14%). Morphological ultrasound scanning revealed anomalies in one fetus. Long-term follow-up included general physical examinations, serological status tested using Western blot, neuro-radiological, ophthalmologic and neurologic examinations, psychological and developmental tests, visual evoked potential tests and audiology tests, as well as anti-Toxoplasma treatment regimes.

RESULTS

Fourteen (17%) of the infants were infected at one-year serological follow-up. Chi-square for linear trend of vertical transmission from the first to the third trimester was significant (P=0.009). Western blot analysis showed IgM and IgA in half of the infected infants. In 69 uninfected infants, anti-Toxoplasma IgG immunoblot analysis excluded infection within the 3 months in 18 infants (26%) and in the others within 6 months of life. The most relevant instrumental findings are described.

CONCLUSION

Western blot analysis may help to evaluate infection within the 6 months of life. The accuracy of ultrasound imaging to determine the brain damage in the fetus and newborns is doubtful, and should be combined with MR imaging. Multistep approaches can improve the timing of postnatal follow-up.

Unusual MRI findings in an immunocompetent patient with EBV encephalitis: a case report

Blackground

It is well-known that Epstein-Barr virus (EBV) can affect the central nervous system (CNS).

Case presentation

Herein the authors report unusual timely Magnetic Resonance Imaging (MRI) brain scan findings in an immunocompetent patient with EBV encephalitis.

Diffusion weighted MRI sequence performed during the acute phase of the disease was normal, whereas the Fast Relaxation Fast Spin Echo T2 image showed diffuse signal intensity changes in white matter. The enhancement pattern suggested an inflammatory response restricted to the brain microcirculation. Acyclovir and corticosteroid therapy was administered. After three weeks, all signal intensities returned to normal and the patient showed clinical recovery.

Conclusion

This report demonstrates that EBV in an immunocompetent adult can present with diffuse, reversible brain white matter involvement in the acute phase of mononucleosis. Moreover, our case suggests that a negative DWI sequence is associated with a favorable improvement in severe EBV CNS infection. More extensive studies are needed to assess what other instrumental data can help to distinguish viral lesions from other causes in the acute phase of disease.

[The return of anthrax. From bioterrorism to the zoonotic cluster of Sciacca district]

Anthrax is a disease caused by Bacillus anthracis which affects herbivorous animals. Humans acquire the disease incidentally by exposure to infected animals, animal products or spores on soil. The infection is still endemic in many regions in developing countries. In Italy animal clusters are very rare and human cases are exceptional. Bacillus anthrax is also a potential source for acts of bioterrorism. In the natural human infection, cutaneous anthrax is the most widespread, while the other two, pulmonary and gastrointestinal anthrax, are very rare forms. We describe the first case of human anthrax occurring in western Sicily in the last twenty years. The cutaneous lesion healed without significant scarring after antibiotic treatment with tigecycline, rifampin and ciprofloxacin. Following our diagnosis, a cluster of bovine anthrax was detected in the district of Sciacca, causing the death of 13 animals. A larger outbreak was avoided by the vaccination of over 5000 herbivores.

Severe Mediterranean spotted fever complicated by acute renal failure and herpetic oesophagitis

Mediterranean spotted fever (MSF) is a tick-borne disease caused by Rickettsia conorii. Recently, complicated cases have been more frequently reported, even in previously healthy patients. We describe a case of severe MSF complicated by acute renal failure and associated with herpetic oesophagitis. Acyclovir therapy resulted in remission of oesophageal symptoms within 48 h.

Cryptic Leishmania infantum infection in Italian HIV infected patients

BACKGROUND

Visceral leishmaniasis (VL) is a protozoan diseases caused in Europe by Leishmania (L.) infantum. Asymptomatic Leishmania infection is more frequent than clinically apparent disease. Among HIV infected patients the risk of clinical VL is increased due to immunosuppression, which can reactivate a latent infection. The aims of our study were to assess the prevalence of asymptomatic L. infantum infection in HIV infected patients and to study a possible correlation between Leishmania parasitemia and HIV infection markers.

METHODS

One hundred and forty-five HIV infected patients were screened for the presence of anti-Leishmania antibodies and L. infantum DNA in peripheral blood. Statistical analysis was carried out by using a univariate regression analysis.

RESULTS

Antibodies to L. infantum were detected in 1.4% of patients. L. infantum DNA was detected in 16.5% of patients. Significant association for PCR-Leishmania levels with plasma viral load was documented (p = 0.0001).

CONCLUSION

In our area a considerable proportion of HIV infected patients are asymptomatic carriers of L. infantum infection. A relationship between high HIV viral load and high parasitemic burden, possibly related to a higher risk of developing symptomatic disease, is suggested. PCR could be used for periodic screening of HIV patients to individuate those with higher risk of reactivation of L. infantum infection.

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.

Analysis of Mycobacterium tuberculosis-specific CD8 T-cells in patients with active tuberculosis and in individuals with latent infection

CD8 T-cells contribute to control of Mycobacterium tuberculosis infection, but little is known about the quality of the CD8 T-cell response in subjects with latent infection and in patients with active tuberculosis disease. CD8 T-cells recognizing epitopes from 6 different proteins of Mycobacterium tuberculosis were detected by tetramer staining. Intracellular cytokines staining for specific production of IFN-γ and IL-2 was performed, complemented by phenotyping of memory markers on antigen-specific CD8 T-cells. The ex-vivo frequencies of tetramer-specific CD8 T-cells in tuberculous patients before therapy were lower than in subjects with latent infection, but increased at four months after therapy to comparable percentages detected in subjects with latent infection. The majority of CD8 T-cells from subjects with latent infection expressed a terminally-differentiated phenotype (CD45RA⁺CCR7⁻). In contrast, tuberculous patients had only 35% of antigen-specific CD8 T-cells expressing this phenotype, while containing higher proportions of cells with an effector memory- and a central memory-like phenotype, and which did not change significantly after therapy. CD8 T-cells from subjects with latent infection showed a codominance of IL-2⁺/IFN-γ⁺ and IL-2⁻/IFN-γ⁺ T-cell populations; interestingly, only the IL-2⁺/IFN-γ⁺ population was reduced or absent in tuberculous patients, highly suggestive of a restricted functional profile of Mycobacterium tuberculosis-specific CD8 T-cells during active disease. These results suggest distinct Mycobacterium tuberculosis specific CD8 T-cell phenotypic and functional signatures between subjects which control infection (subjects with latent infection) and those who do not (patients with active disease).

Monitoring the rate of hospitalization before rotavirus immunization in Italy utilizing ICD9-CM regional databases

BACKGROUND

Recently, two Rotavirus (RV) vaccines were licensed in Italy, rendering RV illness a vaccine preventable disease. To assess the RV hospitalization rate in Italy, a study focused on the Regional hospital discharge forms (HDD) databases was carried out.

RESULTS

Regional HDD databases from Piemonte, Veneto, Friuli-Venezia-Giulia and Marche were analyzed. A total of 434,335 hospitalizations were counted in the study timeframe and 13,234 VE diagnoses (3% of hospitalizations) were collected. A total of 8546 RVE cases (2% of hospitalizations, 64% of all VE) were observed, of which 1.2% were primary diagnoses (PD) and 0.8% secondary diagnosis (SD). The RVE hospitalization peak (4.9%) was observed at the age of 1 year (4.5% in 7-12 months of age) with a median hospital stay of 4.4 days (s.d +/- 4.2). Two deaths (out of 8546 RVE cases) were identified.

PATIENTS AND METHODS

Regional HDD databases with the diagnosis of viral enteritis (VE) and RV enteritis (RVE) (ICD9-CM code 00861-69 and 008.8) in any position of the first 20 discharge diagnoses in children aged less or equal to 5 years between 2001 and 2005 were requested.

CONCLUSION

Despite some limitations due to the HDD synthetic contents and low potential for clinical interpretation, the Regional HDD databases, including PD and SD, may be a useful tool for monitoring the clinical impact of RV vaccination introduction in Italy.

Atrial fibrillation in Mediterranean spotted fever

Mediterranean spotted fever (MSF) is a tick-borne acute febrile disease caused by Rickettsia conorii and characterized by fever, maculo-papular rash and a black eschar at the site of the tick bite (‘tache noir’). We describe the case of a 58-year-old man affected by MSF who developed atrial fibrillation. The patient presented himself to the hospital after 7 days of fever, malaise and severe headache. Cardiac auscultation revealed a chaotic heart rhythm and an electrocardiogram confirmed atrial fibrillation with a fast ventricular response. Diagnosis of MSF was made after the appearance of a maculo-papular skin rash, and treatment with oral doxycycline was started. An immunofluorescence antibody test confirmed R. conorii infection. The patient recovered after 7 days of treatment. Cardiac arrhythmia is a rare complication of MSF. Inflammation may play a role in the pathogenesis of atrial fibrillation. R. conorii is an intracellular bacterium which could trigger atrial fibrillation. Our patient was previously healthy and had no reported history of cardiac disease. This suggests that heart function should be monitored in MSF patients even in the absence of underlying risk factors.

Human toxocariasis: a report of nine cases

AIM

Human toxocariasis is caused by infection with the larval stage of nematode parasites of dogs and cats, Toxocara canis or Toxocara cati. These helminths are not able to complete their life cycle in undefinitive hosts and so undergo aberrant migrations in the tissues causing a wide spectrum of signs and symptoms. Eosinophilia is often severe and sometimes represents the only sign of infection, except in ocular and neurological forms.

METHODS

We describe the clinical features of nine children affected by toxocariasis admitted to our Infectious Diseases department from 2004 to 2006.

RESULTS

Fever and hepatomegaly were the most common clinical findings. In two cases eosinophilia was not present. Diagnosis was performed by enzyme-linked immunosorbent assay employing excretory-secretory antigens of Toxocara. canis larvae. All patients were successfully treated with oral albendazole with no side effects.

CONCLUSION

Toxocariasis should be considered in differential diagnosis of eosinophilia and in patients with seizures of uncertain origin, isolated hepatomegaly and splenomegaly, bronchospasms or skin rash.

Asymptomatic Leishmania infantum/chagasi infection in blood donors of western Sicily

The purpose of this study was to evaluate whether the risk of transfusion-transmitted visceral leishmaniasis was present in an area of western Sicily where the incidence of the disease is higher than the regional average. From May to December 2005, 1449 blood donors from Agrigento district (Sicily, Italy) were screened for the presence of anti-Leishmania antibodies by an indirect immunofluorescent antibody test (IFAT). Blood samples from IFAT-positive donors were examined by PCR to detect Leishmania DNA. Anti-Leishmania antibodies were found in 11 (0.75%) cases, among which Leishmania DNA was detected from four (36.4%). Particular techniques to inactivate different pathogens would be considered mandatory in the case of immunosuppressed recipients.

Respiratory syncytial virus infection in a Sicilian pediatric population: risk factors, epidemiology, and severity

Respiratory syncytial virus (RSV) is the leading cause of hospitalization for lower respiratory tract infections (LRTIs) in young children worldwide. This study evaluated the epidemiological and clinical patterns of RSV infection in infants hospitalized for LRTIs in Sicily. Over a 7-month period (October 1, 2005 to April 30, 2006), all children <2 years of age hospitalized for LRTIs were evaluated and tested for respiratory viruses. Logistic regression was used to identify the risk factors associated with RSV infection and with more severe disease. One hundred sixty-four children were enrolled and 40.9% were found to be RSV(+). The epidemic peak of RSV occurred in April, and no cases were observed in October, November, and December. RSV Infections had the highest incidence in children <3 months of age (54.7%). The likelihood to be RSV(+) rather than RSV(-) was lower for female gender and children >6 months old, with a gestational age (GA) of >36 weeks, with a birth weight of >2.50 g, with previous hospitalizations due to LRTI, with smokers in the household, and with a history of breast-feeding (p < 0.05 for each). RSV infection was associated with a higher likelihood to be admitted to neonatal intensive care units and to longer hospitalizations (p = 0.061). The collected data show that, in Sicily, RSV is an important cause of LRTIs in infants and a variety of factors, such as gender, chronological age at hospitalization, GA, birth weight, and exposure to tobacco smoke and breast-feeding may affect the prevalence of RSV-related lower respiratory tract disease and, possibly, the risk of developing asthma-like symptoms during the school years.

Materno-fetal Toxoplasma gondii infection: critical review of available diagnostic methods

Various critical issues still surround the management of toxoplasmosis in pregnant women and neonates. Although the study of specific antibodies remains an essential parameter for diagnosing materno-fetal infection and establishing time of infection, the method needs to be carefully and critically reviewed due to the distinctive immunological sensitivity of the neonate. We began a retrospective epidemiological study of the pre-natal management of Toxoplasma gondii (TG) infection to evaluate the incidence of congenital toxoplasmosis in children in a southern Italian area (Sicily). 230 children born between 1999 and 2005 to mothers with TG infection during pregnancy enrolled in the G. Di Cristina Children's Hospital of Palermo. Retrospective analysis of the maternal sample established that 150 (65%) of the 230 infants enrolled in the study were born to a mother with probable infection, while the remaining 80 (35%) were born to a mother with definite infection. To date, the results of the neonatal follow-up programme have confirmed the diagnosis of congenital infection in 16 infants (7%); for 43%, diagnosis was made early due to the presence, at birth or in the first month of life, of specific anti-TG IgM. Sequelae were observed in 8/16 infected infants. Sequelae in infected born to mothers with infection in the third trimester opens up the problematic issue of which therapeutic approach to adopt for these women: even without consensus support, a combined regimen of Pyrimethamine-Sulfadiazine could be advocated, even in the absence of prenatal diagnosis. Currently, the best diagnostic strategy involves the sequential or contemporaneous combination of more than one of the currently available methods, as no method on its own can ensure an appropriate level of accuracy.

[Serological screening for Leishmania infantum in asymptomatic blood donors and HIV+ patients living in an endemic area]

Visceral leishmaniasis (VL) is endemic in Sicily (48 new cases in 2004, of which nine were in Agrigento). In southern Europe between 25-70 per cent of adult VL cases are related to HIV infection. The HIV cases have a high risk (1.5-9%) of developing VL either as a new infection or as the revival of a latent infection. We therefore carried out serologic screening to detect antibodies against L. infantum by IFAT in 1449 blood donors in Agrigento and the surrounding area (May-December 2005) and in 120 HIV+ in western Sicily, all of whom were asymptomatic and had no history of VL. L. DNA was assessed by nested PCR in blood samples of some seropositive donors. Of the 1449 blood donors, 11 (0.75%) were positive by IFAT and three of them were also positive in PCR. L. infantum seropositivity is most probably the expression of recent infection because the clearance of serum antibodies is rather fast (6-12 months) after VL. This is why blood donation by Leishmania seropositive donors, whether positive or negative by PCR, could constitute an infection risk especially for immunosuppressed recipients, who should receive deleukocyted blood. Moreover it could be useful to monitor HIV/Leishmania coinfection cases to avoid the risk of slatentization of L. infection when CD4+ levels are very low.

Norovirus and gastroenteritis in hospitalized children, Italy

Noroviruses were detected in 48.4% of 192 children (<3 years of age) hospitalized for gastroenteritis in Palermo, Italy, during 2004; predominant genotypes were GGIIb/Hilversum and GGII.4 Hunter. Of children with viral enteritis, 19.6% had a mixed norovirus-rotavirus infection. The severity of infection was lower for norovirus than for rotavirus but increased in co-infection.

Anti-16-kilodalton mycobacterial protein immunoglobulin m levels in healthy but purified protein derivative-reactive children decrease after chemoprophylaxis

Serum responses against Mycobacterium tuberculosis HSP16 were determined for children with tuberculosis (TB) and for healthy purified protein derivative (PPD)-positive and PPD-negative children. Immunoglobulin G (IgG) and IgM responses were higher for TB patients than for other groups. After chemotherapy, IgM and IgG responses decreased for TB patients and PPD-positive subjects. Monitoring of anti-M. tuberculosis HSP16 responses could assist in the management of pediatric TB.

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.

Clinical use of polymerase chain reaction performed on peripheral blood and bone marrow samples for the diagnosis and monitoring of visceral leishmaniasis in HIV-infected and HIV-uninfected patients: a single-center, 8-year experience in Italy and review of the literature

BACKGROUND

To overcome some of the limitations of conventional microbiologic techniques, polymerase chain reaction (PCR)-based assays are proposed as useful tools for the diagnosis of visceral leishmaniasis.

PATIENTS AND METHODS

A comparative study using conventional microbiologic techniques (i.e., serologic testing, microscopic examination, and culture) and a Leishmania species-specific PCR assay, using peripheral blood and bone marrow aspirate samples as templates, was conducted during an 8-year period. The study cohort consisted of 594 Italian immunocompetent (adult and pediatric) and immunocompromised (adult) patients experiencing febrile syndromes associated with hematologic alterations and/or hepatosplenomegaly. Identification of the infecting protozoa at the species level was directly obtained by PCR of peripheral blood samples, followed by restriction fragment-length polymorphism analysis of the amplified products, and the results were compared with those of isoenzyme typing of Leishmania species strains from patients, which were isolated in vitro.

RESULTS

Sixty-eight patients (11.4%) had a confirmed diagnosis of visceral leishmaniasis. Eleven cases were observed in human immunodeficiency virus (HIV)-uninfected adults, 20 cases were observed in HIV-infected adults, and the remaining 37 cases were diagnosed in HIV-uninfected children. In the diagnosis of primary visceral leishmaniasis, the sensitivities of the Leishmania species-specific PCR were 95.7% for bone marrow aspirate samples and 98.5% for peripheral blood samples versus sensitivities of 76.2%, 85.5%, and 90.2% for bone marrow aspirate isolation, serologic testing, and microscopic examination of bone marrow biopsy specimens, respectively. None of 229 healthy blood donors or 25 patients with imported malaria who were used as negative control subjects had PCR results positive for Leishmania species in peripheral blood samples (i.e., specificity of Leishmania species-specific PCR, 100%). PCR and restriction fragment-length polymorphism analysis for Leishmania species identification revealed 100% concordance with isoenzyme typing in the 19 patients for whom the latter data were available.

CONCLUSIONS

PCR assay is a highly sensitive and specific tool for the diagnosis of visceral leishmaniasis in both immunocompetent and immunocompromised patients and can be reliably used for rapid parasite identification at the species level.

Surveillance of multidrug-resistant gram-negative bacilli in a neonatal intensive care unit: prominent role of cross transmission

BACKGROUND

Multidrug-resistant gram-negative bacilli (MDRGN) are an important cause of nosocomial infections in neonatal intensive care units (NICUs). We conducted a 1-year prospective surveillance study in an NICU to assess the epidemiology of MDRGN among newborns and the relative importance of acquisition routes.

METHODS

Neonates admitted at the NICU of the Dipartimento Materno-Infantile, University Hospital, Palermo, Italy, from January 7, 2003, to January 6, 2004, were included in the study. Colonization of patients with MDRGN was assessed by cultures of rectal swabs sampled twice a week. Pulsed-field gel electrophoresis was used to determine relatedness among MDRGN isolates. Extended-spectrum beta-lactamases (ESBL) and metallo-beta-lactamases (MBL) production was investigated. The association between risk factors at admission and during the NICU stay was analyzed by multivariate logistic regression analysis.

RESULTS

During the 12-month period January 7, 2003, through January 6, 2004, 1021 rectal swabs were cultured from 210 infants. One hundred sixteen infants (55.2%) were colonized by MDRGN. The monthly incidence of acquisition of MDRGN ranged between 12 and 53 cases per 1000 patient-days. Eighty-four (72.4%) of the 116 patients were cross colonized. Exclusive feeding by formula was significantly associated with cross transmission (RR=1.8, P=.02). Fifty-seven (49.1%) of the 116 infants were colonized by ESBL-producing Enterobacteriaceae. Feeding by formula was significantly associated with colonization by ESBL-producing Enterobacteriaceae (RR=1.6, P=.007), whereas breastfeeding proved to be protective (RR=0.5, P=.001). Ninety-two (43.8%) of the 210 infants received antibiotics during the NICU stay, but exposure to those most frequently administered, ampicillin-sulbactam and gentamicin, was not significantly associated with MDRGN colonization.

CONCLUSION

The emerging picture of this study is that spread of MDRGN in an NICU may be the result of diffuse cross transmission and, consequently, of poor infection control procedures.

Decreased serum granulysin levels in childhood tuberculosis which reverse after therapy

Granulysin is a cytolytic protein of natural killer (NK) cells and cytotoxic T lymphocytes (CTLs). Serum levels of granulysin are related to host cellular immunity. We used an ELISA to quantify granulysin serum levels in children with tuberculosis (TB), before and after chemotherapy. The study involved children affected by different clinical forms of TB (n=72) and healthy control children (n=150) from the same geographical area and of similar socio-economic background. Serum granulysin levels before the initiation of TB therapy were significantly lower in children with TB compared to controls, with the lowest levels being found in TB patients who were PPD skin test negative. No statistically significant differences were found between serum granulysin levels and clinical severity (mild/moderate or advanced pulmonary TB) or the clinical form (pulmonary or extra-pulmonary) of TB. At four months after completion of therapy, serum granulysin levels in children treated for TB were not significantly different to those observed in control children. This finding was paralleled by the increased in vitro mycobactericidal activity of sera from TB patients after completion of therapy. We propose that serum granulysin levels may provide a marker of disease activity in childhood TB and might be useful for monitoring improvement after chemotherapy.

[Clinical and microbiological features of Salmonella gastroenteritis in children]

The aim of our study was to evaluate the role of Salmonella spp in children hospitalised for acute gastroenteritis, and to study clinical and microbiological features of paediatric salmonellosis in our geographical area. In all, 540 patients admitted from March to September 2003 with symptoms of acute enteritis to the Infectious Diseases department of the "G. Di Cristina" hospital in Palermo were enrolled. Stool samples were collected within 48 hours of admission and tested for intestinal pathogens (bacterial, viral, parasites). Salmonella spp was detected in 18.5% of samples. The median age of infected children was 4.5 years. Salmonella enteritidis (49%) and Salmonella typhimurium (37%) were the most commonly identified genotypes. S. enteritidis infection was more frequently characterized by vomiting (65.3%) and dehydration (61.2%). Bloody diarrhoea was more common in S. typhimurium infection (40.5%). All strains were susceptible to ceftriaxone, while 40% of strains were resistant to tetracyclines and 37% to ampicillin.

Rotavirus and not age determines gastroenteritis severity in children: a hospital-based study

BACKGROUND

The severity of childhood gastroenteritis is generally believed to be age-related rather than aetiology-related. Rotavirus-induced gastroenteritis is more severe than gastroenteritis caused by other enteric pathogens and is also age-related. We thus addressed the question of whether the increased severity of rotavirus-induced gastroenteritis is related to age or to features intrinsic to the agent.

STUDY DESIGN

In this multicentre, hospital-based, prospective survey, we evaluated the severity of diarrhoea in rotavirus-positive and rotavirus-negative children up to 4 years of age. Severity was assessed with a score in four groups of age-matched children.

RESULTS

Rotavirus was detected in 381 of 911 children. Disease severity was evaluated in 589 cases for which clinical data were complete. The rotavirus-positive and rotavirus-negative groups differed with regards to diarrhoea duration, hospital stay, degree of dehydration and the number of episodes of vomiting. Gastroenteritis was more severe in rotavirus-positive than in rotavirus-negative children. In contrast, none of the main severity parameters differed in the four age groups, irrespective of the presence of rotavirus.

CONCLUSIONS

These data provide the evidence that aetiology and not age determines diarrhoeal severity. The demonstration that diarrhoea was more severe in rotavirus-positive children supports the need for a rotavirus vaccine and for studies that address the duration of vaccine protection.

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.

[Hormonal, auxological and clinical follow-up in children with connatal HIV infection: personal records]

Auxological and endocrinological complications frequently occur in children with connatal HIV infection. These complications seem to be related both to the infection itself and the antiretroviral therapy. Many children consequently show height-weight and pubertal retardation without any evidence of hormonal deficit. We studied 10 children with connatal HIV infection who were enrolled in this analysis and followed up for 7 years in order to evaluate their height-weight growth, pubertal maturation, bone age progression and hormonal pattern [basal Growth hormone (GH) and GH after Clonidine or Insulin stimulation, Insulin-like Growth Factor 1 (IGF-1), Insulin-like Growth Factor Binding Protein 3 (IGFBP-3), FSH, LH, ACTH and Cortisol, TSH, fT4, T4, T3, Ab-TGO, Leptin]. Three children showed a height lower than 3rd centile during the first two years of their life and in prepubertal age, with recurring improvement in their growth rate. Weight growth was very compromised in one girl, remaining firmly lower than 3rd centile during the follow-up. Three children presented a weight lower than 3rd centile until they were two years old. However, a height growth rate higher than 10th centile was found in nine children throughout the follow-up, while it was pathological in five children. The blood level of Leptin was higher at the beginning of the study: 0.82 - 11.68 ng/l (M+/-DS: 3.29+/-4.15) than at its conclusion: 0.2 - 3 ng/l (M+/-DS: 1.65+/-1.01). There was a statistically significant correlation between leptinemia and the CD4/CD8 count (p: 0.010; r: 0.916) and the CDC classification (p: 0.006; r: 0.937), indicating a strong relationship with the degree of virological and immunological impairment. The authors stress the importance of a careful height-weight growth rate control in HIV-infected children, as it reflects the clinical and virological course of the disease. Adequate control of the infection allows physiological growth in most patients. Moreover, we emphasize the utility of IGFBP-3 and IGF-1 measurements, since they represent growth markers which are more exact and better capable of reproduction than GH.

Mediterranean spotted fever: clinical and laboratory characteristics of 415 Sicilian children

BACKGROUND

Mediterranean spotted fever (MSF) is an acute febrile, zoonotic disease caused by Rickettsia conorii and transmitted to humans by the brown dogtick Rhipicephalus sanguineus. Nearly four hundred cases are reported every year (mainly from June to September) on the Italian island of Sicily. The aim of the study was to analyze the clinical and laboratory characteristics of patients with MSF and the efficacy of the drugs administered.

METHODS

Our study was carried out on 415 children with MSF, during the period January 1997-December 2004, at the "G. Di Cristina" Children's hospital in Palermo, Sicily, Italy. On admission patients' clinical history, physical and laboratory examination and indirect immunofluorescence antibody test (IFAT) for Rickettsia conorii were performed. Diagnosis was considered confirmed if the patients had an MSF diagnostic score greater than or equal to 25 according to the Raoult's scoring system. All patients were treated with chloramphenicol or with macrolides (clarithromycin or azithromycin).

RESULTS

Fever, rash and tache noire were present in 386 (93%), 392 (94.5%) and 263 (63.4%) cases respectively. Eighteen (4.6%) children showed atypical exanthema. Chloramphenicol and newer macrolides all appeared to be effective and safe therapies.

CONCLUSION

Clinical features of 415 children with MSF were similar to those reported by other authors except for a lower incidence of headache, arthralgia and myalgia and a higher frequency of epato-splenomegaly. Concerning therapy, clarithromycin can be considered a valid alternative therapy to tetracyclines or chloramphenicol especially for children aged < eight years.

[Hospitalisation associated with Rotavirus gastroenteritis in Italy, 2001-2003, evaluated by means of ICD9-CM diagnostic codes]

Rotaviruses (RV) are the most common etiological agents in acute gastroenteritis (GE) in children in the first years of life. Data from the national scientific literature show that RV is responsible of 26% of all cases of hospitalisation for diarrea in children, resulting the most frequently identified agent. The Italian database of hospital discharge, freely available from the web site of the national Ministry of Health, was searched to investigate the epidemiology of RV gastroenteritis. The mean number of hospitalisation for RV enteritis in children in the first 4 years of live was 4.758 in the years 2001, 2002 and 2003, representing 84% of viral enteritis. RV was identified as agent in 17% of all intestinal infectious diseases in this age group. This percentage shows the important role of RV in severe gastrointestinal infections; it is however much lower than the value expected from specifically performed surveys. This underestimation may be attributed to the high number of undefined gastroenteritis found in the database (54%), to the scarce sensitivity of the hospital discharge code, and to the fact that the analysis was performed using only the principal diagnosis. A specific immunisation strategy, safe, effective, cost-effective and easy to perform, could have a great impact on the incidence of the disease and on the associated costs.

Typhoid fever as a cause of opportunistic infection: case report

Background

Typhoid fever is a systemic infection caused by the bacterium Salmonella enterica subspecies enterica serotype typhi, which is acquired by ingestion of contaminated food and water. Each year the disease affects at least 16 million persons world-wide, most of whom reside in the developing countries of Southeast Asia and Africa. In Italy the disease is uncommon with a greater number of cases in Southern regions than in Northern ones.

Case presentation

We report on a 57-year-old Sri-Lankan male affected by typhoid fever, the onset of which was accompanied by oropharyngeal candidiasis. This clinical sign was due to a transient cell-mediated immunity depression (CD4+ cell count was 130 cells/mm³) probably caused by Salmonella typhi infection. Human immunodeficiency virus infection was ruled out. Diagnosis of typhoid fever was made by the isolation of Salmonella typhi from two consecutive blood cultures. The patient recovered after a ten days therapy with ciprofloxacin and his CD4+ cell count improved gradually until normalization within 3 weeks.

Conclusion

Our patient is the first reported case of typhoid fever associated with oropharyngeal candidiasis. This finding suggests a close correlation between Salmonella typhi infection and transitory immunodepression.

[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.

Serological screening for Leishmania infantum in asymptomatic blood donors living in an endemic area (Sicily, Italy)

The purpose of our study was to assess whether Leishmania infantum parasitemia occurs in asymptomatic Leishmania-seropositive subjects. Samples from 500 blood donors were tested using an enzyme-linked immunosorbent assay (ELISA). Anti-Leishmania antibodies were not found in any sample. Our findings suggest that the risk of L. infantum transmission by blood transfusion in Sicily is very low.

[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.

[Postnatal follow-up of infants born to mothers with certain Toxoplasma gondii infection: evaluation of prenatal management]

The clinical management of perinatal toxoplasmosis involves a gynaecologist during pregnancy and a neonatologist after delivery. Then, in the absence of a uniform approach, early evaluation of infected infants requires a thorough long-term follow-up also in asymptomatic children, who have to be observed for at least one year due to unpredictable sequelae in later life. We retrospectively analyzed pregnancy management of 54 women with certain infection from Toxoplasma gondii (TG) and prospectively enrolled their infants to compare prenatal management with postnatal clinical outcome. All mothers with seroconversion for TG infection were from the Palermo area and were retrospectively analyzed, whereas their newborns referred to G. Di Cristina Children Clinical Hospital between 1999-2004 were prospectively enrolled in a 48-month follow-up. Timing of infection was dated for 24 women (45%) to the first trimester, 18 (33%) to the second and 12 (22%) the third. The maternal-fetal transmission rate was 17.2%. Prenatal diagnosis from amniotic fluid was performed in 25/54 pregnant subjects and showed positive results in 6. Despite diagnosis of TG infection, 9 women were untreated and only 2 with positive amniocentesis received combined therapy. 10/55 enrolled infants were infected and half of them were preterm and/or SGA at birth. None showed peculiar signs of TG at birth but 4 had abnormalities during the follow-up. 9/10 infected children were born to mothers who had undergone neither amniocentesis nor combined therapy.

CONCLUSIONS

Our work confirms the difficulty of applying standardized therapeutic protocol for TG infection during pregnancy. The asymptomatic course of TG infection at birth confirms the importance of an instrumental long-term follow-up to identify typical TG lesion to prevent sequelae.

Th0 to Th1 switch of CD4 T cell clones specific from the 16-kDa antigen of Mycobacterium tuberculosis after successful therapy: lack of involvement of epitope repertoire and HLA-DR

In this study, we have examined the influence of HLA-DR molecules and the structure of the epitope repertoire of the 16-kDa protein of Mycobacterium tuberculosis on the acquisition of the cytokine secretion pattern of CD4 T cell clones, obtained from tuberculous patients before and after anti-mycobacterial therapy. Our data indicate that TB patients have a predominant Th0 response against the 16-kDa protein and its epitopes and that healing, induced by anti-mycobacterial therapy, is associated with a shift toward a predominant Th1 phenotype. Moreover, both HLA-DR molecules restricting the clone specificity and the nature of the recognized epitope do not play any role in the generation of Th0 and Th1 clones. These findings indicate that additional factors, such as the cytokine environment and/or costimulatory molecules, determine the Th phenotype of CD4 T cells during tuberculosis.