G. Lo Cascio

Utility of molecular identification in opportunistic mycotic infections: a case of cutaneous Alternaria infectoria infection in a cardiac transplant recipient.

ABSTRACT We report on a case of cutaneous infection caused by Alternaria infectoria in a cardiac transplant recipient. A rapid molecular diagnosis was obtained by sequence analysis of the internal transcribed spacer domain of the 5.8S ribosomal DNA region amplified from colonies developed on Sabouraud medium. Treatment consisted of a combination of systemic antifungal therapy, first with amphotericin B and then with itraconazole.

Latent tuberculosis infection in patients with chronic plaque psoriasis who are candidates for biological therapy

Screening for latent tuberculosis infection (LTBI) is mandatory in patients with psoriasis prior to biological therapy.

Antimicrobial Susceptibility of Respiratory Isolates of Enterobacteriaceae and Staphylococcus aureus in Italy: Incidence and Trends Over the Period 1997-1999

The antibiotic susceptibility of members of the family Enterobacteriaceae and of Staphylococcus aureus strains isolated from the respiratory tract was assessed over the period 1997–1999 as part of the Italian Epidemiological Observatory survey sponsored by the SmithKline Foundation. A standardised method was used to determine the MICs of 22 antibiotics against isolates of Klebsiella pneumoniae (n=870), Escherichia coli (n=684), Enterobacter cloacae (n=342), Enterobacter aerogenes (n=187) and Serratia marcescens (n=135) as well as the MICs of 11 antibiotics against isolates of Staphylococcus aureus (n=1,606). Overall, the susceptibility rate of Enterobacteriaceae isolates was ≥90% to 5 agents (meropenem, imipenem, amikacin, cefepime and gentamicin); 89–80% to 2 agents (ciprofloxacin and tobramycin); and <80% to 11 agents (cefotaxime, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, cefetamet, ceftriaxone, ceftazidime, aztreonam, ticarcillin-clavulanate, tetracycline, piperacillin, cefuroxime, chloramphenicol, ticarcillin, amoxicillin-clavulanate and amoxicillin). During the 3-year monitoring period, antibiotic susceptibility increased in Klebsiella pneumoniae against amoxicillin-clavulanate, in Escherichia coli against third-generation cephalosporins and aztreonam, in Enterobacter aerogenes against amoxicillin and piperacillin-tazobactam and in Serratia marcescens against most of the antibiotics. In contrast, Enterobacter cloacae showed a tendency to develop resistance to cefetamet, amikacin and ciprofloxacin. Of the total number of Staphylococcus aureus strains, 38% were methicillin resistant. Nearly 80% of the methicillin-resistant strains displayed a multiresistance pattern (additional resistance to 2 or more non-beta-lactam antibiotics). Rates of susceptibility of particular species (Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus) were compared using strains from different geographical areas of Italy (northern, central and southern) and from different nosocomial areas (outpatients, intensive care unit [ICU] inpatients, non-ICU inpatients). Susceptibility of Klebsiella pneumoniae to several antibiotics was lower in southern Italy, whereas the incidence of methicillin-resistant strains was higher in northern and central Italy. The susceptibility of Escherichia coli was similar in all three areas. No significant differences in susceptibility of Klebsiella pneumoniae or Escherichia coli were found between strains from inpatients and outpatients or from inpatients admitted to ICU and non-ICU units. The incidence of methicillin-resistant Staphylococcus aureus was higher in ICU inpatients (52%) than in non-ICU inpatients (38%) and lower in outpatients (19%) than in inpatients.

Diagnostic Aspects of Cutaneous Lesions due to Histoplasma capsulatum in African AIDS Patients in Nonendemic Areas

Histoplasmosis is a mycosis caused by a dimorphic saprophytic fungus, Histoplasma capsulatum, known as an environmental mould. Primary infection occurs through inhalation of spores, causing a self-limited disease in at least 95% of immunocompetent hosts. In immunocompromised individuals, especially patients with AIDS, Histoplasma capsulatum can produce progressive disseminated disease, which may prove fatal if untreated [1]. Two variants of Histoplasma capsulatum are known, namely, var. capsulatum, reported in the USA, Central and South America, and South Africa, and var. duboisii, reported exclusively in the African continent, i.e., West Africa (Senegal, Mali, Burkina-Faso, Ivory Coast) and Central and Equatorial Africa (Chad, Congo, Zaire). Even though Europe is not an endemic area 131 cases were reported between 1995 and 1999 in a survey of histoplasmosis (Ashbee R, oral presentation at the European Conference on Medical Mycology, Barcelona, 2000). An Italian survey reported 26 cases in the 1990s [2], and there have been several reports of disseminated histoplasmosis occurring in AIDS patients from Africa [3, 4, 5]. A review of the latest reports of African cases draws attention to the similarity of clinical presentation (particularly cutaneous involvement) among these cases compared with those occurring in South America. The pleomorphic presentation of the mucocutaneous lesions and the susceptibility of AIDS patients to opportunistic infections could delay the clinical and laboratory diagnosis in non-endemic areas. Therefore, a high index of suspicion is needed to make an early diagnosis and to permit rapid differentiation of the condition from most others with which disseminated histoplasmosis can be confused and thus misdiagnosed, i.e., secondary syphilis, AIDS-associated prurigo, cryptococcosis, candidosis, molluscum contagiosum and Penicillium marnefei disease. Reported here is the case of a 40-year-old black woman from Nigeria, who was diagnosed with HIV in January 2002 and who had immigrated to the Verona district of Italy in the year 2000. She was suffering from nephrotic syndrome and congestive edema of the nasal and pharyngeal mucosa. Until January 2002 she had been receiving antiretroviral therapy, but she failed to comply regularly with the administration regimen. In July 2002 she was admitted to our hospital with major labial and glottal edema and localized facial skin lesions, described as papular-ulcerative, that later spread to the arms and trunk. Her CD4+ lymphocyte count was 14 cells/mm3 and her T4/T8 score was 0.02%. Histopathology (Grocott’s and periodic acid-Schiff stain) of the skin biopsy sample revealed the presence of yeast-like elements measuring 3– 5 m in diameter. The definitive diagnosis was made by cultivation of the organism from skin biopsy in Sabouraud glucose agar at 24 C and brain heart infusion agar at 37 C to obtain the yeast phase. Isolation of the pathogen required 1–2 weeks, and identification was based on the evidence of specific warted macroconidia of Histoplasma capsulatum and conversion to the yeast phase. Positive urease activity differentiated var. capsulatum from var. duboisii. Confirmation was obtained using molecular identification as described previously [6]. Two pairs of PCR primers were first designed to develop a nested PCR assay to amplify the DNA region of Histoplasma capsulatum. These primers were based on the sequence of a gene coding for a 100-kDa-like protein unique to Histoplasma capsulatum deposited in the GenBank database (accession number AJ005963) [7]. Primers Hc I (50-GCG TTC CGA GCC TTC CAC CTC G. Lo Cascio ()) Servizio di Microbiologia, Azienda Ospedaliera di Verona, Ospedale Policlinico G.B. Rossi, Piazzale Scuro 10, 37134 Verona, Italy e-mail: giuliana.locascio@azosp.vr.it Tel.: +39-045-8074682 Fax: +39-045-584159

First Case of Bloodstream Infection Due to Candida magnoliae in a Chinese Oncological Patient

ABSTRACT We report a case of fungemia caused by Candida magnoliae, a yeast never associated with human disease. The infection occurred in a 42-year-old Chinese patient with gastric cancer complicated by peritoneal carcinosis. Multiple blood cultures were positive for yeast; the species was well identified with biochemical and molecular methods. The phylogenetic analysis showed a close relationship of C. magnoliae to Candida krusei.