Ginevra Marinacci

Reactivation of severe, acute pulmonary tuberculosis during treatment with pegylated interferon-alpha and ribavirin for chronic HCV hepatitis

The unexpected observation of severe pulmonary tuberculosis after a 7-month combined pegylated interferon-ribavirin for chronic hepatitis C, prompted us to search an eventual immunodeficiency (lymphopenia and/or depletion of CD4+ T-lymphocytes. The retrieval of a chest radiograph incidentally performed 11 y before and showing a probable primary tuberculosis, paralleled a negligible clinical history. The enlargement of interferon indications needs careful evaluation for prior (usually missed) tuberculosis, to prevent or avoid its possible reactivation. Latent tuberculosis is increasingly reported because of extended life expectancy, immigration, and recent availability of cure for multiple chronic disorders, which are often borne by primary-secondary immunodeficiency.

Community-acquired Pseudomonas aeruginosa sacro-iliitis in a previously healthy patient.

Pyogenic sacro-iliitis is an uncommon osteo-articular infection that occurs usually in immunocompromised patients and is associated with gram-positive cocci. It is very rarely linked with a gram-negative aetiology. The first case of Pseudomonas aeruginosa sacro-iliitis is described, which occurred in a previously healthy young man, without history of prior traumatic events, hospitalisation or chronic underlying disease.

Listeria monocytogenes Meningitis and Multiple Brain Abscesses in an Immunocompetent Host. Favorable Response to Combination Linezolid-Meropenem Treatment

Central nervous system (CNS) listeriosis outside of pregnancy, the neonatal period, and immunodeficiency, is uncommon in the general population. Although Listeria sepsis-bacteremia, endocarditis, gastroenterit is, and focal infection has been described, meningitis and especially CNS abscess lead to major diagnostic and therapeutic concerns 1,2. CNS involvement should follow bacteremia, and meningitis represents the most common CNS manifestation, with brain abscesses being <1% of episodes of Listeria CNS involvement 3. Multiple predisposing factors have been described in anecdotal reports and small adult and pediatric series of patients suffering from hematologic or solid organ malignancies 1,2,4, collagen vascular disease and chronic intestinal disorders, while HIV disease is not considered a supporting factor. Isolated episodes of L. monocytogenes CNS infection were also reported in immunocompetent patients 5,6, where differential diagnosis and treatment are hampered by a low clinical suspicion. A literature review from 1945 to 1984 retrieved 45 cases of listeriosis, 54% of them occurring in apparently immunocompetent hosts, Journal of Chemotherapy Vol. 18 n. 3 (331-333) 2006

Pentamidine Isethionate as Treatment and Secondary Prophylaxis for Disseminated Cutaneous Leishmaniasis During HIV Infection: Case Report

Abstract Leishmaniasis is emerging as a common and serious opportunistic infection in HIV-infected patients in endemic areas (such as Mediterranean countries), and may occur with various clinical presentations, ranging from typical visceral forms to atypical cases, including cutaneous disease. Although pentavalent antimony compounds have been the mainstay of antileishmanial treatment for half a century, new drugs seem today reliable, including liposomal ampho-tericin B and pentamidine isethionate. However, the most effective therapy is still unknown. An HIV-infected i.v. drug abuser patient with a very uncommon disseminated cutaneous leishmaniasis, following an initial visceral disease, is described. Primary and recurrent visceral forms of protozoan infection have been treated with liposomal amphotericin B, while pentamidine isethionate was successfully employed as treatment for subsequent cutaneous relapse and as secondary prophylaxis.

Meningoencephalitis with Persistent Parvovirus B19 Infection in an Apparently Healthy Woman

A case of meningoencephalitis, associated with persistent parvovirus B19 infection, is described in a 36-year-old immunocompetent woman. Parvovirus B19 DNA was detected in samples of cerebrospinal fluid and serum; no parvovirus B19-specific clinical symptoms were seen, but neurological episodes were observed in the presence of parvovirus B19 infection and despite the onset of a specific immune response.

Disseminated histoplasmosis with atypical cutaneous lesions in an Italian HIV-infected patient: another autochtonous case

Disseminated histoplasmosis is recognized as a common AIDS‐defining opportunistic disease in endemic areas (Americas, Africa, East Asia), while it is rarely described in Europe, usually in individuals returning from endemic regions, or following endogenous reactivation of a latent infection imported long before from overseas countries. However, reports of autochtonous cases in Europe suggest the possible, endemic presence of Histoplasma capsulatum in some European regions, such as the South of France or the Po valley in Italy. A case of disseminated histoplasmosis with atypical, papular and ulcerate skin lesions in an Italian HIV‐infected patient, without history of travels outside his native region, is described. Our patient represents the fifth autochtonous case of AIDS‐associated histoplasmosis described in Italy.

Role of Mycobacterium xenopi disease in patients with HIV infection at the time of highly active antiretroviral therapy (HAART). Comparison with the pre-Haart period

BACKGROUND AND SETTING A reliable and timely clinical, radiological, and bacteriological diagnosis, and an optimal treatment of non-tubercular mycobacteriosis (including Mycobacterium xenopi disease), remain an unanswered challenge for clinicians facing immunocompromised patients, including those with HIV infection. OBJECTIVE The aim of our survey is to report the frequency, and the epidemiological, immunological, microbiological, clinical, and therapeutic features of all confirmed HIV-associated M. xenopi disease observed from 1993-2002, with special attention paid to eventual differences that emerged after the introduction of potent antiretroviral therapy (highly active antiretroviral therapy, HAART), on the basis of an international literature update. DESIGN AND RESULTS Our series of 17 consecutive confirmed M. xenopi infections retrieved in 14 out of 3000 patients followed for HIV disease complications raises a broad series of clinical, diagnostic, therapeutic, and prophylactic concerns. The great majority of M. xenopi disease involved the lower respiratory tract, but atypical features including cavitation and prominent exudative features became apparent in patients successfully treated with HAART, pointing out the possible role of the so-called immune reconstitution syndrome in these episodes. CONCLUSIONS Diagnostic problems represented by late or missed identification due to slow culture and frequently concomitant opportunistic disorders, join therapeutic difficulties due to the unpredictable in vitro antimicrobial susceptibility profile of these organisms, selection of treatment and chemoprophylaxis according with clinical-radiological and microbiological suspicion, and concomitantly administered medications.

Chron's disease, rare association with selective IgA immunodeficiency, and development of life-threatening bacterial infections

Life-threatening necrotizing fasciitis and relapsing Lemierre syndrome associated with Fusobacterium necrophorum septicaemia occurred in young adults with a moderate Chrons disease and a missed profound IgA deficiency. This unexpected association of a chronic bowel inflammatory syndrome with prominent IgA abnormalities and severe bacterial infection deserves careful attention by physicians faced with young patients with Chrons disease.

SIMULTANEOUS OCCURRENCE OF VISCERAL LEISHMANIASIS AND DISSEMINATED HISTOPLASMOSIS IN AN ITALIAN PATIENT WITH HIV INFECTION

Both disseminated histoplasmosis and visceral leishmaniasis are being recognised with increasing frequency as opportunistic infections in HIV-infected patients, predominantly in their respective endemic areas. In fact, AIDS-related disseminated Histoplasma capsulaturn infection is relatively common in highly endemic areas of Northern and Central America and Africa [1] and is rarely observed in non-endemic regions such as Europe (where only a few isolated cases have been seen [2-6]), whereas HIV-associated visceral leishmaniasis has been reported primarily from several hypo-endemic regions, such as Spain, Southern France and Italy [7-9]. A case of fatal simultaneous infection by H. capsulatum and Leishmania is described in an Italian HIV-infected patient. Four weeks after coming back from a trip in Mexico and Central America, a 29-year-old ex-IV drug abuser presented with fever, severe weight loss, arthromyalgia, cough and dyspnoea. He previously received zidovudine and aerosolised pentamidine for primary prophylaxis of Pneumocystis carinii infection; chloroquine antimalarial chemoprophylaxis had been carried out correctly, during and after the recent journey. Clinical examination showed liver and spleen enlargement, polyadenopathy and oropharyngeal candidiasis, while a chest radiograph revealed bilateral reticulonodular infiltrates. Laboratory findings showed a severe immunosuppression (total leukocyte count 1,990/mm 3, CD4+ lymphocytes 48/ram 3) and anaemia, thrombocytopenia, hypergammaglobulinaemia and elevation of serum AST-ALT, alkaline phosphatase, gamma-GT and LDH. When blood cultures yielded Staphylococcus epidermidis and acid-fast bacilli were recovered from bronchoalveolar lavage, an antibiotic treatment (ceftazidime plus netilmicin) and a four-drug tuberculostatic regimen were started together with fluconazote for oral candidiasis, without any improvement of the clinical picture. Visualisation of the typical Leishmania amastigotes in Giemsa stain of smears of bone marrow aspirates established a diagnosis of visceral leishmaniasis (Figure 1A and Figure 1C). An initial treatment with meglumine antimoniate (20 mg/Kg/day) associated with allopurinol was replaced by pentamidine (4 mg/Kg/day) after 9 days because of the occurrence of adverse events (cardiotoxicity and hypotension). In spite of treatment, clinical conditions progressively worsened, showing hyperpyrexia, impressive hepatosplenomegaly, severe anaemia and thrombocytopenia, leading to death 5 weeks after admission with a septic shock-like syndrome characterised by hypotension, multi-organ failure and disseminated intravascular coagulation. Relatives refused necropsy examination. Two weeks after the patients death, H. capsulatum was recovered from five consecutive blood specimens cultured for Mycobacterium spp. on Middlebrook 7H9 Base radiometric medium (MB Check, Hoffmann-La Roche, Basel, Switzerland) after an overall 20-day incubation. Subcultures made on brain-heart infusion agar at 37°C (yeast phase), and Saboraud dextrose agar at room temperature (reversion into the mycelial phase, with demonstration of septate hyphae and characteristic large tuberculate macroconidia), confirmed the diagnosis. A successive review of bone marrow smears stained with periodic acid-Schiff led to the identification of a large amount of intracellular fungal organisms, together with Leishmania amastigotes (Figure 1 B), while Leishmania serology made with an indirect immunofluorescence assay on three consecutive serum samFigure 1A: Giemsa stain of a bone marrow specimen showing Leishmania amastigotes as 1-2 txm intracytoplasmatic bodies (thin arrow), together with intracellular organisms consistent with the yeast form of Histoplasma capsulatum (thick arrow).

Progressive Intractable Actinomycosis in Patients with AIDS

Two rare cases of progressive oropharyngeal actinomycosis, characterized by a subacute and invasive course despite seemingly appropriate antibiotic and surgical treatment, have been observed in patients with AIDS. A brief review of previously reported cases of actinomycosis in HIV-infected patients is presented. Clinical, diagnostic and therapeutic problems dealing with actinomycosis in the immunocompromised host are discussed.