Antonello Malfitano

Performance of Real-Time Strain Elastography, Transient Elastography, and Aspartate-to-Platelet Ratio Index in the Assessment of Fibrosis in Chronic Hepatitis C

OBJECTIVE The purpose of this article is to evaluate the diagnostic performance of transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index in assessing fibrosis in patients with chronic hepatitis C by using histologic Metavir scores as reference standard. SUBJECTS AND METHODS Consecutive patients with chronic hepatitis C scheduled for liver biopsy were enrolled. Liver biopsy was performed on the same day as transient elastography and real-time strain elastography. Transient elastography and real-time strain elastography were performed in the same patient encounter by a single investigator using a medical device based on elastometry and an ultrasound machine, respectively. Diagnostic performance was assessed by using receiver operating characteristic curves and area under the receiver operating characteristic curve (AUC) analysis. RESULTS One hundred thirty patients (91 men and 39 women) were analyzed. The cutoff values for transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index were 6.9 kPa, 1.82, and 0.37, respectively, for fibrosis score of 2 or higher; 7.3 kPa, 1.86, and 0.70, respectively, for fibrosis score of 3 or higher; and 9.3 kPa, 2.33, and 0.70, respectively, for fibrosis score of 4. AUC values of transient elastography, real-time strain elastography, aspartate-to-platelet ratio index were 0.88, 0.74, and 0.86, respectively, for fibrosis score of 2 or higher; 0.95, 0.80, and 0.89, respectively, for fibrosis score of 3 or higher; and 0.97, 0.80, and 0.84, respectively, for fibrosis score of 4. A combination of the three methods, when two of three were in agreement, showed AUC curves of 0.93, 0.95, and 0.95 for fibrosis scores of 2 or higher, 3 or higher, and 4, respectively. CONCLUSION Transient elastography, real-time strain elastography, and aspartate-to-platelet ratio index values were correlated with histologic stages of fibrosis. Transient elastography offered excellent diagnostic performance in assessing severe fibrosis and cirrhosis. Real-time elastography does not yet have the potential to substitute for transient elastography in the assessment of liver fibrosis.

Performance of liver stiffness measurements by transient elastography in chronic hepatitis

AIM To compare results of liver stiffness measurements by transient elastography (TE) obtained in our patients population with that used in a recently published meta-analysis. METHODS This was a single center cross-sectional study. Consecutive patients with chronic viral hepatitis scheduled for liver biopsy at the outpatient ward of our Infectious Diseases Department were enrolled. TE was carried out by using FibroScan™ (Echosens, Paris, France). Liver biopsy was performed on the same day as TE, as day case procedure. Fibrosis was staged according to the Metavir scoring system. The diagnostic performance of TE was assessed by using receiver operating characteristic (ROC) curves and the area under the ROC curve analysis. RESULTS Two hundred and fifty-two patients met the inclusion criteria. Six (2%) patients were excluded due to unreliable TE measurements. Thus, 246 (171 men and 75 women) patients were analyzed. One hundred and ninety-five (79.3%) patients had chronic hepatitis C, 41 (16.7%) had chronic hepatitis B, and 10 (4.0%) were coinfected with human immunodeficiency virus. ROC curve analysis identified optimal cut-off value of TE as high as 6.9 kPa for F ≥ 2; 7.9 kPa for F ≥ 3; 9.6 kPa for F = 4 in all patients (n = 246), and as high as 6.9 kPa for F ≥ 2; 7.3 kPa for F ≥ 3; 9.3 kPa for F = 4 in patients with hepatitis C (n = 195). Cut-off values of TE obtained by maximizing only the specificity were as high as 6.9 kPa for F ≥ 2; 9.6 kPa for F ≥ 3; 12.2 kPa for F = 4 in all patients (n = 246), and as high as 7.0 kPa for F ≥ 2; 9.3 kPa for F ≥ 3; 12.3 kPa for F = 4 in patients with hepatitis C (n = 195). CONCLUSION The cut-off values of TE obtained in this single center study are comparable to that obtained in a recently published meta-analysis that included up to 40 studies.

Efficacy of a short-term amphotericin B + flucytosine combination therapy followed by itraconazole monotherapy in acute and chronic AIDS-associated cryptococcosis

Summary. The authors report the clinical and microbiological findings of a 6‐month follow‐up of nine AIDS patients affected with cryptococcosis. Among these, seven patients suffered from meningoencephalitis and two from disseminated infection. The antifungal therapy during acute illness included the administration of amphotericin B at doses of 0.6 mg kg‐1 day‐1 i.v. plus flucytosine at doses of 100 mg kg‐1 day‐1 i.v. during the first 15 days followed by itraconazole at doses of 400 mg day‐1 p.o. in the following 15 days. The maintenance treatment included itraconazole at doses of 200 mg day‐1 p.o. indefinitely. During the 6‐month follow‐up, one patient died of hepatic failure related to C virus (HCV) hepatitis reactivation and another patient died of polymicrobial pneumonia. In two patients, the presence of multiple nodular lesions in the cerebral computerized tomography (CT) scan, related to cryptococcal granulomas, was associated with the persistance of fungi in the cerebrospinal fluid. In three patients with meningoencephalitis the three‐drugs regimen was effective in eradicating the neurological infection, and relapses were not observed during the maintenance therapy with itraconazole during the 6‐month follow‐up. The two patients with haematogenous cryptococcosis did not relapse after the 6‐month follow‐up.

Human Immunodeficiency Virus-Associated Malignancies: A Therapeutic Update

Implementation of highly active antiretroviral therapy (HAART) has deeply changed the landscape of HIV-associated malignancies. Some AIDS-defining tumors, namely Primitive Lymphoma of Central Nervous System, have drastically declined, whereas a steady increase has been observed for non-AIDS-defining tumors, maybe due to longer survival of HIV-infected people. Easier immune restoration, subsequent to availability of a number of drugs targeting HIV at different points, has decreased opportunistic infections which hampered treatment of HIV-associated cancers. As a matter of fact these patients have been assimilated more and more with their negative counterpart, undergoing the same aggressive approach. Consistently, procedures that have been so far precluded to HIV+ subjects, such as transplant of hemopoietic stem cells, either autologous or allogenic, and liver transplant are expected to be performed more and more extensively in this population. Which also would mean a full removal of the stigma which has weighed on it. Hence, it is true-like that malignancies and related problems may in the next future make up a main concern for the HIV specialist. Old and new challenges might be the drug-drug interaction of antiretrovirals or biotherapy-related infections or the debated question of an earlier HAART implementation in the course of HIV disease, with CD4+ cells > 500/μl. In fact, if assimilation of HIV patients with cancer and the general population is a remarkable achieved goal, uniqueness of HIV infection in terms of immune status still makes HIV-associated cancer a unique chapter in the setting of Oncology.

Complete Remission of Multicentric Castleman's Disease developed in a HIV+ Patient after the Start of HAART

In August 2010, we diagnosed a Multicentric Castleman’s Disease (MCD) in a HIV+ patient with generalized lymphadenopathy, splenomegaly and pericardial effusion. A few days before the onset of symptoms, the patient had started anti-retroviral therapy with Abacavir/Lamivudine (ABC/3TC) +Ritonavir-boosted Atazanavir (ATV/r). During the hospitalization he developed a severe pancytopenia with liver failure, and he started immediately the Therapy with steroids, Ganciclovir, and Rituximab. At the 46 months follow-up, the patient is asymptomatic, his biochemical values are essentially normal with a complete regression of the superficial and deep lymphadenopathies.

Oligohydramnios in a pregnant Pakistani woman with Plasmodium vivax malaria

In the Western world, the diagnosis and management of Plasmodium vivax malaria in pregnant women can be challenging, and the pathogenesis of adverse outcomes for both the mother and the foetus is still poorly known. The authors describe the case of a 29-year-old Pakistani woman at the 29th week of her second pregnancy, who was admitted to the Hospital following the abrupt onset of fever. At the time of admission, she had been living in Italy without travelling to any malaria-endemic areas for eight months. She was diagnosed with vivax malaria after a thin blood smear revealed the presence of plasmodial trophozoites and gametocytes and treated accordingly. Due to the onset of oligohydramnios, she underwent caesarian section at the 31st week of pregnancy with no further complications. Histological examination of the placenta showed no evidence of plasmodial infection, but was inconclusive. It is unclear whether oligohydramnios is a complication of pregnancy-related Plasmodium vivax malaria. Given the long latency of hypnozoites, every febrile pregnant patient with a previous stay in an endemic area should be screened for malaria with a thick and a thin blood smear.

Ongoing change in the treatment of HIV-associated malignancies in the HAART era

Implementation of highly active antiretroviral therapy (HAART) has changed the epidemiology, clinical outcome and therapeutic approach of HIV-associated malignancies. Whereas Kaposi sarcoma and primary CNS non-Hodgkin lymphoma have decreased dramatically, systemic non-Hodgkin lymphoma incidence seems unchanged, perhaps increasing as with other tumor incidence. Owing to HAART-induced immune function preservation, response rates to chemotherapy and survival times in patients with HIV-associated malignancies have neared those observed in their HIV-negative counterparts. Hence, intensive regimens have been more and more extensively used with promising results. This may also apply to other therapeutic options, such as biotherapy, and procedures, such as stem cell rescue following high-dose chemotherapy or heterologous stem cell transplant, which have so far been precluded to HIV-infected subjects as a matter of fact. A trend toward a full assimilation of HIV-infected people with cancer and the general population with the same pathology is ongoing.

Fast relapse and high drop out rate of 48 weeks daily interferon monotherapy in HIV-infected patients with chronic hepatitis C

BackgroundThe standard of care for HCV Hepatitis is the combination of interferon (IFN) plus Ribavirin. In HIV patients the use of this combination therapy may induce drug interactions, and reduces the adherence to HAART.The aim of this study is to evaluate safety and efficacy of a 48 weeks daily dose IFN schedule.MethodsWe evaluated 50 coinfected patients; alpha IFN 2a was administered at a dose of 3 MU daily. The baseline values were the following : CD4+ 515 cells/mmc (mean); HIV-RNA <50 copies/ml in all patients; HCV-RNA 28, 3 × 106 copies/ml.ResultsAt 48 weeks, 10 patients (20%) achieved a biochemical and virological response according to an intention to treat analysis.Twenty four patients (48%) underwent a drop-out mainly by side effects related to overlapping toxicity of interferon and antiretroviral therapy. All the patients, who responded to the treatment, showed a fast relapse one month after the end of treatment.ConclusionAlthough our results demonstrated a very poor outcome and a bad tolerance to interferon monotherapy, this approach should not be dropped out, mainly in patients at high risk for side effects and in those with cirrhosis who do not tolerate or are at increased risk for the use of ribavirin.

Isoenzyme analysis of Entamoeba histolytica for evaluation of pathogenicity: detection of zymodeme XIX in South America.

SummaryAuthors report the results of the isoenzyme analysis of strains ofEntamoeba histolytica isolated from international travellers. This recently developed method allows the detection of pathogenic strains by evaluating the electrophoretic mobility of cytoplasmic enzymes and was proved to be more reliable and quickly feasible than previous ones. The experience reported refers to three strains isolated from travellers coming from Ecuador, Brazil and Indonesia, respectively; the zymodeme XIX (in accordance with the Sargeaunt’s classification) was identified in all the three cases. This zymodeme has been first detected in 1981 and should currently be considered rare; moreover, it has never been previously reported from the Americas.