Luciano Nigro

Slower Progression of HIV-1 Infection in Persons with GB Virus C Co-Infection Correlates with an Intact T-Helper 1 Cytokine Profile

Context Patients infected with HIV-1 progress to AIDS more slowly if they are co-infected with hepatitis G virus, also called GB virus C (GBV-C), than if they are not. The mechanism of this effect of GBV-C infection is not known. Contribution Among 80 asymptomatic HIV-1infected patients, T-helper 1 cytokine profiles changed unfavorably in those without GBV-C infection and remained stable in those with GBV-C infection. Implications Co-infection with GBV-C may slow progression of HIV-1 infection through a mechanism related to T-helper 1 cytokines. The Editors Hepatitis G virus, also called GB virus C (GBV-C), is a recently identified RNA virus belonging to the Flaviviridae family (1, 2). It is usually transmitted parenterally (2, 3). The prevalence of GBV-C viremia ranges from 20% to 24% among persons who use intravenous drugs (4, 5). Higher rates have been seen in patients with HIV-1 infection, regardless of intravenous drug use (4, 6). In recent surveys, HIV-1infected persons with GBV-C co-infection had better AIDS-free survival rates and higher CD4+ cell counts than HIV-1infected patients who were GBV-C negative (7-10). It has also been shown that GBV-C inhibits HIV-1 replication in vitro (11). Our objective was to evaluate AIDS-free survival rates, plasma HIV-1 viral load, and selected immunologic variables in 80 HIV-1seropositive patients with and without GBV-C co-infection. We sought to determine possible immunologic mechanisms involved in these co-infection scenarios. Methods The study was initiated between January and March 1989 at the Institute of Infectious Diseases, University of Catania, Catania, Italy. Institutional review boards at the Institute of Infectious Diseases, University of Catania, approved the follow-up protocol. Signed informed consent was obtained from each patient. Among 319 HIV-1seropositive patients, 240 used intravenous drugs, 60 were homosexual men, and 19 had received many blood transfusions. Eighty of these 319 patients (25%), all of whom used intravenous drugs, were asymptomatic and were enrolled in a prospective follow-up study to evaluate the progression of HIV-1related disease. All 80 patients underwent physical examination and routine blood biochemistry examinations every 6 months. Blood samples were obtained annually from each patient, and serum was stored at 80 C until use. The analyses for the current study were begun in January 1997. Quantitative plasma HIV-1 RNA levels and circulating levels of specific interleukins (ILs)IL-2, IL-4, IL-10, and IL-12were retrospectively determined in all serum samples. We determined GBV-C RNA levels in all serum specimens collected at the beginning of the study and at the end of follow-up. Analyses were repeated in January 2001. Anti-E2 antibodies were detected by using the Enzymun-Test Anti-HGenv (Boehringer Mannheim Corp., Indianapolis, Indiana). Plasma HIV-1 RNA copy numbers were determined by using the nucleic acid sequence-based amplification method (NASBA, Organon Teknika, Boxtel, the Netherlands). The sensitivity limit of the assay was 400 copies/mL. Interleukin-2 was analyzed by using a quantitative enzyme immunoassay (Predicta, Genzyme Diagnostics, Cambridge, Massachusetts) with a sensitivity limit of 4 pg/mL. Interleukin-4 was tested by using a quantitative enzyme immunoassay (InterTest, Genzyme Diagnostics) with a sensitivity limit of 0.045 ng/mL. Interleukin-10 was measured by using a competitive enzyme immunoassay (Cytokit Red 10, Genzyme Diagnostics), which had a range of detection between 0.195 and 200 ng/mL. Interleukin-12 levels were determined by using an enzyme immunoassay provided by R&D Systems (Oxon, United Kingdom) that had a lower sensitivity limit of 5 pg/mL. We measured GBV-C RNA level by using reverse transcriptase polymerase chain reaction, as described elsewhere (12). Statistical Analysis Plasma HIV-1 RNA levels were logarithmically transformed to normalize their distribution. Categorical variables were analyzed by using the Fisher exact test. The group means were compared by using the Student t-test. Variations of all interim values of plasma HIV-1 RNA level, CD4+ cell count, and IL levels were analyzed within each group by using two-way analysis of variance. We compared GBV-C RNApositive and GBV-C RNAnegative groups by using the MannWhitney U test to examine percentage variations from baseline values to values at the end of follow-up. Curves reflecting variations by time in immunologic and virologic variables were compared by using univariate repeated-measures analysis that followed an analysis-of-variance structure (13). Progression to AIDS was defined as the development of an opportunistic infection or malignant condition. We used the Kaplan-Meier method to evaluate the effect of GBV-C infection on AIDS-free survival by assuming that GBV-C and HIV-1 infection status was fixed at the beginning of follow-up. A P value less than 0.05 was considered statistically significant. Statistical analyses were performed by using SAS software, version 6.12 (SAS Institute, Inc., Cary, North Carolina). Role of the Funding Sources The funding sources had no direct control over the analysis of the study. Results The mean age of the study patients (SD) was 24.6 2.2 years. Fifty-two patients were men, and 28 were women. Mean duration of intravenous drug use (SD) was 24.2 1.8 months, and mean duration of known HIV-1 seropositivity (SD) was 9.2 1.6 months. The mean baseline CD4+ cell count (SD) was 471 55 109 cells/L. Fifty-eight patients declined to take any antiretroviral drug, and 6 were treated with zidovudine alone throughout the follow-up period. In 16 patients, didanosine was added to zidovudine, starting in 1993. In January 1997, follow-up was interrupted and all 80 patients began to receive different highly active antiretroviral therapy (HAART). At this time, 6 patients were asymptomatic, 24 had stage B disease, and 50 had stage C disease, according to stages defined by the U.S. Centers for Disease Control and Prevention. At the end of follow-up, the mean CD4+ cell count (SD) was 77 33 109 cells/L. Seventeen of the 80 serum specimens collected at the beginning of follow-up (21%) were positive for GBV-C RNA. All of these 17 patients maintained GBV-C viremia to the end of the follow-up period, and none of the 63 patients who were GBV-C RNA negative acquired the infection. Patients who were GBV-C negative and those who were GBV-C positive did not significantly differ in age, sex, duration of intravenous drug use and HIV-1 seropositivity, or rate of hepatitis C virus and hepatitis B virus infection (Table). Table. Epidemiologic and Virologic Variables Measured at Baseline and at the End of Follow-up Clinical Outcomes At the end of the 8-year follow-up, 3 of 17 GBV-Cpositive patients (18%) remained asymptomatic (stage A), 7 (41%) had stage B disease, and 7 (41%) had stage C disease. In the 7 patients with stage C disease, the following AIDS-defining diseases were observed: AIDS dementia complex (n = 7 [100%]), Pneumocystis carinii pneumonia (n = 4 [57%]), esophageal candidiasis (n = 3 [43%]), and Toxoplasma encephalitis infection (n = 1 [14%]). Three of 63 GBV-C RNAnegative patients (5%) had stage A disease, 17 (27%) had stage B disease, and 43 (68%) had stage C disease. Among those with stage C disease, the following diseases were observed: P. carinii pneumonia (n = 18 [42%]), esophageal candidiasis (n = 11 [26%]), Toxoplasma encephalitis infection (n = 5 [12%]), cryptococcal meningitis (n = 4 [9%]), intestinal cryptosporidiosis (n = 3 [7%]), Kaposi sarcoma (n = 2 [5%]), AIDS dementia complex (n = 2 [5%]), and disseminated cytomegalovirus disease (n = 1 [2%]). According to Kaplan-Meier curves showing progression to AIDS in HIV-1infected persons, cumulative AIDS-free survival rates at 24 and 48 months, respectively, were 0.5 (95% CI, 0.3 to 0.6) and 0.4 (CI, 0.3 to 0.5) in the GBV-Cnegative group and 0.9 (CI, 0.7 to 1.0) and 0.7 (CI, 0.5 to 0.9) in the GBV-Cpositive group (P = 0.02 for between-group comparisons). Mean AIDS-free survival time was 73 months (CI, 59 to 87 months) among GBV-Cpositive persons and 45 months (CI, 35 to 54 months) among GBV-Cnegative persons. Immunologic and Virologic Evaluations The Figure shows the cross-sectional averages of IL levels, CD4+ cell counts, and HIV RNA levels during the follow-up period. Annual plasma HIV-1 RNA levels significantly increased during follow-up in both the GBV-Cnegative and GBV-Cpositive groups, whereas CD4+ cell counts significantly decreased (P < 0.01 for all comparisons). In the GBV-Cnegative group, IL-4 and IL-10 levels increased significantly from baseline (P = 0.01 and P = 0.004, respectively) but IL-2 and IL-12 concentrations decreased significantly throughout the entire follow-up period (P = 0.005 and P = 0.01, respectively). In contrast, in the GBV-Cpositive group, none of the measured cytokine levels changed significantly during follow-up. The Table shows the percentage variation from baseline to the end of follow-up in plasma HIV-1 RNA levels, CD4+ cell counts, and cytokine concentrations between the two groups. Figure. Cross-sectional averages of interleukin ( IL ) levels, CD4+ cell counts, and HIV-1 RNA levels in GB virus C ( GBV-C )-positive and GBV-Cnegative patients during 8 years of follow-up. P P Response to HAART In January 1997, all 80 patients began taking HAART. Among the 17 GBV-Cpositive patients, 10 received zidovudine, lamivudine, and saquinavir and 7 received zidovudine, lamivudine, and indinavir. Among the 63 GBV-Cnegative patients, 20 were treated with zidovudine, lamivudine, and saquinavir; 20 were treated with zidovudine, lamivudine, and indinavir; 13 were treated with zidovudine, didanosine, and indinavir; and 10 were treated with zidovudine, lamivudine, and ritonavir. Fourteen patients, 2 in the GBV-Cpositive group and 12 in the GBV-Cnegative group, stopped taking HAART between 1997 and 2001 because of personal preference, lack of adh

A Placebo-Controlled Treatment Trial of Blastocystis hominis Infection with Metronidazole

Blastocystis hominis, previously considered a harmless yeast, is now classified as a protozoan inhabiting the human intestinal tract. The pathogenicity of B. hominis remains controversial and is currently the subject of extensive debate.1- 5 As a result of the uncertainty surrounding the pathogenic role of B. hominis, large-scale treatment trials of B. hominis infection have so far been lacking. In spite of this, several drugs have been reported to be active against the parasite.6-8 The present study was carried out in order to evaluate the efficacy of metronidazole treatment in inducing clinical remission and parasitologic eradication in immunocompetent individuals with B. hominis as the only evident cause of diarrhea.

Reduction of Serum Melatonin Levels in HIV-1- Infected Individuals' Parallel Disease Progression: Correlation with Serum Interleukin-12 Levels

Abstract.Background:During the natural history of human immunodeficiency virus type I (HIV-1) infection, an impairment of interleukin-12 (IL-12) production precedes a switch from a T-helper 1 (Th1) to a T-helper 2 (Th2) stage of cellular immunity. Melatonin, the main hormone produced by the pineal gland, seems to promote a Th1 response by increasing the production of IL-12 in vitro. The aim of this study was to measure and correlate serum levels of melatonin and IL-12 in a cohort of HIV-1-infected individuals.Patients and Methods:77 anti-HIV-1-positive subjects were enrolled: 20 were in CDC stage A, 25 in CDC stage B and 32 in CDC stage C. 30 healthy HIV-1-seronegative subjects were recruited as controls. IL-12 and melatonin concentrations were quantitated in serum samples.Results:Mean levels of serum melatonin were significantly lower in HIV-1-infected individuals in comparison with controls (p < 0.001). Within the HIV-1-seropositive group, mean melatonin and IL-12 concentrations were significantly lower in patients in CDC stage C, as compared with patients in CDC stages B and A (p < 0.01).Conclusion:During the natural history of HIV-1 disease, serum melatonin levels are progressively reduced. This reduction may be related to the impairment of Th1 immunoresponses.

A Human Case of Hymenolepis diminuta in a Child from Eastern Sicily

We report a case of Hymenolepis diminuta infection in a 2-year-old child living in a suburban area of Catania, Italy. This case was initially referred to us as Dipylidium caninum infection, which was not cured after being treated twice with mebendazole. However, by analyzing the clinical presentation and stool samples we arrived to the diagnosis of H. diminuta infection. The case presented with atypical allergic manifestations which had never been reported as clinical features of symptomatic H. diminuta infection; remittent fever with abdominal pain, diffuse cutaneous itching, transient thoracic rash, and arthromyalgias. The patient was treated with a 7-day cycle of oral niclosamide, which proved to be safe and effective. This case report emphasizes that a correct parasitological diagnosis requires adequate district laboratories and trained personnel. In addition, we recommend the importance of reporting all H. diminuta infection cases, in order to improve knowledge on epidemiology, clinical presentation, and treatment protocols.

HCV and HBV infection among multitransfused thalassemics from eastern sicily

SummarySerum specimens from 152 Sicilian multitransfused thalassemic subjects were tested for antibodies to hepatitis C virus (anti- HCV) and for HBV markers by enzyme linked immunoassay and with reference to anti-HCV, confirmed by recombinant immunoblot assay. A high rate (47%) of subjects was anti-HCV positive. HBsAg was found in 8% of patients and 55% had anti-HBs or anti-HBc antibodies or both. Contrary to HBV infection, anti-HCV seropositivity was related to the number of transfused units. The highest anti-HCV prevalence was observed between 16 and 20 years; 100% of persons older than 50 years had at least one marker of HBV infection. In conclusion, HCV and HBV are widespread among multitransfused thalassemics. Probably in our area, particularly during the pre-HBsAg screening era, several multitransfused patients were infected by HBV more readily than by HCV.ZusammenfassungDie Seren von 152 Thalassämie-Patienten, die häufig Bluttransfusionen erhalten hatten, wurden auf Antikörper gegen Hepatitis-C-Virus und HBV-Marker getestet. Ein hoher Prozentsatz (47%) erwies sich als anti-HCV positiv, was mit RIBA bestätigt wurde. HBsAg wurde bei 8% der Patienten gefunden und 55% hatten anti-HBc-oder Anti-HBs-Antikörper. Die dominierende anti-HCV-Prävalenz stand in Beziehung zur Transfusionshäufigkeit und war zwischen dem 16. und 20. Lebensjahr am höchsten. Im Gegensatz dazu stand die HBV-Infektion nicht im Verhältnis zu der Anzahl der Bluttransfusionen; bei 100% der Patienten über 50 Jahre wurde mindestens ein HBV-Infektionsmarker beobachtet. Bei Thalassämie-Patienten sind HCV- und HBV-Infektionen verbreitet. Wahrscheinlich haben sich vor dem Beginn des HBsAg-Screening in den Blutbanken viele Patienten mit dem HB-Virus infiziert.

CCR5 and CCR3 expression on T CD3+ lymphocytes from HIV/Leishmania co-infected subjects

CC chemokine receptor 5 (CCR5) and CC chemokine receptor 3 (CCR3) are membrane-bound proteins involved in HIV-1 entry into susceptible cells. All T lymphocyte subsets display CCR5 and CCR3 on their membrane surface. T helper 1 cells are known to express CCR5 but not CCR3, and most of T cells expressing CCR3 are T helper 2. This study aimed to assess the expression of CCR5 and CCR3 on peripheral blood CD3+ T lymphocytes of HIV-Leishmania co-infected individuals. A total of 36 subjects were enrolled; nine had HIV-Leishmania co-infection; nine were HIV-infected without Leishmania, nine had visceral leishmaniasis without HIV co-infection and nine were healthy blood donors. HIV-Leishmania co-infected subjects showed a significantly higher rate of CCR5+CD3+ T lymphocytes in comparison with the other studied groups. The higher rate of CD3+ T-cells expressing CCR5 found in HIV-Leishmania co-infected subjects may be related to the role of Leishmania as an enhancer of the progression to AIDS.

Five-Year Retrospective Italian Multicenter Study of Visceral Leishmaniasis Treatment

ABSTRACT The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

Treatment of Visceral Leishmaniasis: a Five Years Retrospective Italian Multicentric Study

ABSTRACT The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

Feasibility in needle exchange programme: an evaluation of a pilot programme in Catania, Sicily

INTRODUCTION Intravenous drug use (10 V) is a primary transmission route for HIV and other blood borne disease. A criminal approach to illicit drug use leads to aggressive attitudes towards drug users and forces them underground, thus hindering their access to Health Service outlets. A 6-month pilot Needle Exchange Programme was set up in Catania, with the aim of reducing the negative effects and consequences of drug use, preventing the spread of blood borne diseases by encouraging the use of clean needles and reduction of needle sharing. To establish contact with the hidden population of the citys, intravenous drug users (IDUs) and promote condom use and safer sex. METHOD An equipped camper was parked daily in two of the citys main public squares according to a preset timetable, morning and afternoon. A flexible needle exchange policy, i.e. free clean needles given out regardless of those returned, was adopted as a strategy considered necessary in order to, ensure maximum user-friendliness. Safer shooting information leaflets were given out alongside material for the correct use of the condom and condoms. RESULT The number of IDUs, contacted who had previously been referred to a National Health Service Drug Unit (Ser.T.) and not, and number of syringes exchanged were low but increased month by month. CONCLUSION Future projects should be undertaken after building up, a collaborative network between Street Unit and local courts; the city police force; social service outlets; hospitals and other health outlets; Ser.T. units and local pharmacies. In the light of our current experience, the one to one strategy instead to the flexible strategy could lead to stricter adherence to harm reduction strategies amongst IDUs.

Does transient elastography (FibroScan®) have a role in decision making in hepatocellular carcinoma?

OBJECTIVES Portal hypertension has been reported as a negative prognostic factor and a relative contraindication for liver resection. This study considers a possible role of fibrosis evaluation by transient elastography (FibroScan(®)) and its correlation with portal hypertension in patients with cirrhosis, and discusses the use of this technique in planning therapeutic options in patients with hepatocellular carcinoma (HCC). METHODS A total of 77 patients with cirrhosis, 42 (54.5%) of whom had HCC, were enrolled in this study during 2009-2011. The group included 46 (59.7%) men. The mean age of the sample was 65.2 years. The principle aetiology of disease was hepatitis C virus (HCV)-related cirrhosis (66.2%). Liver function was assessed according to Child-Pugh classification. In all patients liver stiffness (LS) was measured using FibroScan(®). The presence of portal hypertension was indirectly defined as: (i) oesophageal varices detectable on endoscopy; (ii) splenomegaly (increased diameter of the spleen to ≥ 12 cm), or (iii) a platelet count of <100,000 platelets/mm(3). RESULTS Median LS in all patients was 27.9 kPa. Portal hypertension was recorded as present in 37 patients (48.1%) and absent in 40 patients (51.9%). Median LS values in HCC patients with and without portal hypertension were 29.1 kPa and 19.6 kPa, respectively (r = 0.26, P < 0.04). Liver stiffness was used to implement the Barcelona Clinic Liver Cancer algorithm in decisions about treatment. CONCLUSIONS   The evaluation of liver fibrosis by transient elastography may be useful in the follow-up of patients with cirrhosis and a direct correlation with portal hypertension may aid in the evaluation of surgical risk in patients with HCC and in the choice of alternative therapies.