Claudio Maria Mastroianni

Central nervous system involvement as a relapse of disseminated histoplasmosis in an Italian AIDS patient

A case of an Italian AIDS patient who developed both meningitis and cerebral mass lesion as a final relapse of disseminated histoplasmosis is reported. Central nervous system (CNS) involvement occurred while the patient was receiving both amphotericin B and itraconazole as maintenance therapy, thus indicating the difficulty of eradicating histoplasmosis in patients with AIDS.

Serologic responses to Rhodococcus equi in individuals with and without human immunodeficiency virus infection

Thirty healthy blood donors, 15 workers from horse-breeding farms, 69 human immunodeficiency virus (HIV)-negative persons at risk for HIV infection, 125 HIV-infected subjects withoutRhodococcus equi infection, and nine HIV-infected patients withRhodococcus equi pneumonia were evaluated in order to detect serum antibodies toRhodococcus equi precipitate-soluble antigen by an enzyme immunoassay (EIA). Whereas EIA values for healthy donors, horse farm workers, individuals at risk for HIV infection, and HIV-positive subjects withoutRhodococcus equi infection were comparable, HIV-infected patients with rhodococcal disease had significantly higherRhodococcus equi antibody levels (p<0.0001). The clinical outcome ofRhodococcus equi pneumonia was more severe in subjects who had low levels of specific antibodies, whereas patients who recovered had elevatedRhodococcus equi antibody levels over time. Immunoblot studies showed that bothRhodococcus equi-infected patients and foals recognized a protein band of approximately 60 kDa in theRhodococcus equi precipitate-soluble antigen. On the other hand, theRhodococcus equi-infected patients did not react with the diffuse 15 to 17 kDa virulence-associated proteins that represent important virulence factors both in mice and horses.

Successful treatment of Stenotrophomonas maltophilia soft tissue infection with tigecycline: a case report.

Stenotrophomonas maltophilia is a nonfermentative, Gram-negative bacillus of increasing importance as a nosocomial pathogen. S. maltophilia has been implicated in a broad spectrum of clinical syndromes, including pneumonia, bloodstream infection, skin infections and surgical-site-related infections 1-4. S. maltophilia shares with other emerging multidrug-resistant Gram-negative organisms the ability to produce betalactamase enzymes involved in the hydrolysis of betalactam-based antibiotics, such as penicillins, cephalosporins and carbapenems. The treatment of nosocomial infections due to S. maltophilia is difficult and controversial 5. Trimethoprim-sulfamethoxazole (TMP-sMx) is the antimicrobial agent of choice, but it is bacteriostatic and increased resistance to this agent has been reported. in addition this pathogen is frequently associated with other multidrug resistant bacteria in the setting of polymicrobial infections. Tigecycline, a new semisynthetic glycylcycline, shows in vitro activity against S. maltophilia, but its efficacy in clinical settings is yet to be established 6. Here, we report a case of S. maltophilia surgical wound infection with surrounding soft tissue involvement which was successfully treated with tigecycline. A 17-year-old male was admitted to Emergency Department of our Hospital because of a compound fracture of his left tibia, rupture of femoral artery and wide soft tissues loss of the leg, due to a road accident. He underwent salvage combined surgery with reduction and osteosynthesis of fracture and arterial bypass. After 4 days, the patient developed fever (39.5°C), dehiscence of surgical incision with purulent drainage involving deep soft tissues of the leg. no evidence of muscle localization was found by computed tomography (CT) scan. Laboratory findings showed: hemoglobin 13.5 g/dl; white blood cells 12,500/mm3 with 80% of neutrophils; platelets, 170,000/mm3. Erythrocyte sedimentation rate was 52 mm/h (normal range, 0–30 mm/h), and his C-reactive protein concentration was 9.6 mg/dL (normal values 0.50 mg/dL). Liver and kidney function were normal. Empiric antibiotic treatment with piperacillintazobactam and teicoplanin was started; the patient also underwent hyperbaric oxygen therapy and surgical debridement of devitalized tissue from wound. Culture of the debridement material grew S. maltophilia susceptible to TMP-sMx (MiC<2 mg/mL) only. Thus, the patient started treatment with TMP-sMx (2 tablets of 160/800 mg 3 times daily), but after 4 days he developed an allergic rash. TMP-sMx was substituted with tigecycline (100 mg loading dose, then 50 mg every 12 hours). After 4 days of monotherapy with tigecycline, we observed a reduction in both fever and signs of local inflammation. This antibiotic was combined with cefepime (2 g i.v. twice daily) because of subsequent isolation of susceptible pseudomonas aeruginosa in the same site of infection. The combined antibiotic treatment was continued for 15 days and led to progressive resolution of local inflammation and microbiological eradication. S. maltophilia represents an emerging and difficult-to-treat nosocomial pathogen. The response to therapy is influenced by several factors, including the genotypic and phenotypic variability of S. maltophilia species, intrinsic resistance mechanisms, the ability to develop resistance during treatment and the lack of standardized susceptibility tests. in addition, in vitro findings cannot be translated into clinical practice because there are no randomized clinical trials which compare the efficacy of different antimicrobial regimens. The Clinical and Laboratory standards institute (CLsi) recommends the disk diffusion technique in order to establish the susceptibility of S. maltophilia to TMP-sMx, minocycline, and levofloxacin. Other agents may be used for therapy, but according to the CLsi, their performance has not been sufficiently studied to establish disk diffusion breakpoints 6. Tigecycline exhibits potent activity against a wide spectrum of bacteria, including methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, penicillin-resistant Streptococcus pneumoniae, enterococcus faecium. Tigecycline has limited or no in vitro activity against p. aeruginosa, while the drug has been reported to be active in vitro against AcineREpRInt

Late onset invasive pneumococcal disease in a liver transplanted patient: beyond the Austrian syndrome

Invasive disease caused by Streptococcus pneumoniae is a major cause of morbidity and mortality in high‐risk individuals with severe comorbidities, including asplenia, chronic alcoholism, and altered immune status. The risk of invasive pneumococcal disease has been significantly higher in transplant patients compared with the general population. Here, we report an unusual case of a disseminated pneumococcal infection with meningitis, endocarditis, spondylodiscitis, and muscle abscess in an asplenic patient on chronic immunosuppressive therapy for liver transplantation performed 17 years before.

Quantitative ultrasound (QUS) in HIV-infected patients: a reliable and low-cost technique for bone health assessment

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Legionella pneumophila pneumonia during telaprevir-based triple therapy for HCV chronic hepatitis.

The recent introduction in clinical practice of two directacting antiviral agents (DAAs), such as telaprevir and boceprevir, has dramatically improved the rate of virologic response in patients with chronic hepatitis C virus (HCV) genotype 1 [1]. However, challenges to the use of DAAs in combination with pegylated interferon alfa (PegIFN) ? ribavirin (RBV) include the potential for drug–drug interactions and a lower safety profile, especially in patients with compromised liver function. A high incidence of severe infections has been recently reported in a cohort of HCV cirrhotic patients receiving triple antiviral therapy [2]. Here, we report the case of a non-cirrhotic HCVinfected patient who developed severe Legionella pneumophila pneumonia during telaprevir-based triple therapy. A 65-year old man chronically infected with HCV genotype 1b who did not achieve a sustained virologic response after a prior course of PegIFN/RBV therapy was recruited to start triple anti-HCV therapy. He had a history of controlled diabetes mellitus and hypertension. The patient underwent three cycles of standard antiviral treatment before treatment initiation with DAAs, the last of which was started in July 2007 and consisted of PegIFNa2b 120 lg once a week ? RBV 1,200 mg daily. This treatment was stopped at week 12 because the drop in HCV-RNA levels was less than 2 log compared to the initial viremia. The patient was therefore considered to be a null responder to the previous standard of care therapy based on IFN and RBV. At the time of enrollment to triple therapy, the patient had increased alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels (73 IU/ L and 124 IU/L, respectively). Haemoglobin was 14.8 g/ dL; white cell count, 6,140 cell/mmc; platelet count, 166,000/mmc. Albuminemia was 4.5 g/dL, and coagulation parameters and renal function were normal. Plasma HCV-RNA was 6.5 log10 IU/mL, and the IL28 polymorphism CT was detected. Liver ultrasound fibroelastography (fibroscan) documented a liver stiffness of 11.8 kPa (Metavir score F3). Screening for autoantibodies was negative; serology for immunodeficiency virus, hepatitis B, hepatitis A, and syphilis was negative. In March 2013, antiHCV triple therapy was started with a combination of PegIFNa2a (180 lg/weekly), weight-based dose of RBV (1,200 mg/daily), and the NS3-4A serine protease inhibitor telaprevir (2,250 mg daily). After 4 weeks of treatment, the plasma HCV-RNA dropped to undetectable levels and remained negative during subsequent evaluations. During treatment, the platelet count fell (65,000/mmc) and haemoglobin decreased to 11.2 g/dL. After 8 weeks of treatment a maculo-papular erythematous eruption involving the anterior surface of both legs was observed. No constitutional symptoms were present, visible mucous membranes were normal, and no lymphoadenopathy developed. Blood tests were stable and eosinophils were within normal range. Skin lesions fully resolved within 4 days with antihistamines and hydration. After 11 weeks of triple therapy, the patient was hospitalized because of abrupt onset of fever, cough, diarrhea, and dyspnea. On admission the patient was slightly confused. Physical examination revealed a pulse rate of 88 beats/min, a respiratory rate of T. Tieghi R. Marocco V. Belvisi C. Del Borgo S. Savinelli M. Lichtner C. M. Mastroianni Department of Public Health and Infectious Diseases, Fondazione Eleonora Lorillard Spencer Cenci, Sapienza University, Latina, Italy