Orazio Ranno

An uncommon presentation for a severe invasive infection due to methicillin-resistant Staphylococcus aureus clone USA300 in Italy: a case report

BackgroundMethicillin resistant Staphylococcus aureus (MRSA) has been considered for many years a typical nosocomial pathogen. Recently MRSA has emerged as a frequent cause of infections in the community. More commonly, community-acquired (CA)-MRSA is a cause of infections of the skin and soft-tissues, but life-threatening infections such as necrotizing pneumonia and sepsis can occasionally occur.Case presentationThis report describes an uncommon presentation of invasive CA-MRSA infection in an adolescent without known risk factors. The presentation was typical for bacterial meningitis, but the clinical findings also revealed necrotizing pneumonia. Following the development of deep venous thrombosis, the presence of an inherited trombophilic defect (factor V Leiden) was detected. The patient was successfully treated with an antibiotic combination including linezolid and with anticoagulant therapy. CA-MRSA was isolated from both cerebrospinal fluid and blood. The isolates were resistant to oxacillin and other beta-lactam antibiotics and susceptible to the other antibiotics tested including erythromycin. Molecular typing revealed that the strains contained the Panton-Valentine leukocidin genes and type IV SCCmec, and were ST8, spa type t008, and agr type 1. This genetic background is identical to that of the USA300 clone.ConclusionThis report highlights that meningitis can be a new serious presentation of CA-MRSA infection. CA-MRSA strains with the genetic background of the USA300 clone are circulating in Italy and are able to cause severe infections.

A 20-Year Retrospective Study of Pediatric Tuberculosis in Two Tertiary Hospitals in Rome

Background: Tuberculosis (TB) is among the top 10 causes of child death worldwide. Nevertheless, childhood disease has been neglected by tuberculosis control programs. Methods: This was a retrospective study of patients < 16 years of age diagnosed with active TB in 2 tertiary hospitals in Rome (Italy), between 1990 and 2009. Results: Two hundred fourteen cases of active tuberculosis were identified (132 definite, 82 probable). Pulmonary involvement was the most common form (75.5%), followed by lymphadenopathy (15.4%) and central nervous system TB (11%). Fever (51.86%) and cough (40%) were the most common presenting symptoms. A total of 23.4% of children were asymptomatic on admission. Sensitivities of the tuberculin skin test and the quantiferon test were 93.4% and 97%, respectively. Both tests performed in 52 children agreed in 49 cases (94%). Sensitivities for culture, Ziehl–Neelsen staining and polymerase chain reaction were 58%, 25% and 66.3%, respectively. The adult source case was identified in 28% of cases. History of contact with a patient with active TB was associated with pulmonary TB (P = 0.0014), whereas negative history of contact was associated with lymph node (P = 0.0064) and central nervous system TB (P = 0.05). Conclusions: Our study emphasizes the difficulty in managing children with suspected TB, because the absence of constitutional symptoms cannot exclude TB, and bacteriologic confirmation is the exception. Immunologic diagnosis can be a valuable tool to identify TB-infected children because the quantiferon test showed high sensitivity in all age groups. This is of primary importance because early identification of children with latent tuberculous infection and appropriate chemoprophylaxis represent, to date, the most important tool to reduce the burden of TB.

Maternal and neonatal characteristics of an immigrant population in an Italian hospital

Objective. The objective of this study was to evaluate clinical and epidemiological characteristics of the maternal and neonatal immigrant population and to compare it with the Italian population in the Agostino Gemelli Hospital (Rome). Methods. This study was a prospective population-based study. We compared 595 newborns from immigrant mothers with 2413 newborns from Italian mothers. Neonatal characteristics included in this study were sex, gestational age, birth weight, Apgar score, transfer to pathology units, minor pathologies, and type of breastfeeding at discharge. Maternal characteristics included nationality, age, parity, type of delivery, twin birth, and pathology during the pregnancy. Results. Immigrant newborns comprised 20% of the total births included in the study. No statistically significant differences were found between immigrant and Italian newborns in gestational age, birth weight, or Apgar score. Immigrant newborns were transferred to the Paediatric Infectious Disease Unit more frequently than Italian newborns, had a significantly higher incidence of hyperbilirubinemia and a higher rate of exclusive and prevalent breastfeeding at discharge. Immigrant mothers came predominantly from Eastern Europe, were younger and had caesarean sections less frequently than Italian mothers. Conclusion. No significant differences in biological and clinical characteristics or in medical practice were found between groups, except for a higher frequency of neonatal hyperbilirubinemia and an inclination among immigrant mothers toward breastfeeding.

Role of spiramycin/cotrimoxazole association in the mother-to-child transmission of toxoplasmosis infection in pregnancy.

The purpose of this report is to evaluate the efficacy and safety of spiramycin/cotrimoxazole in the mother-to-child transmission of Toxoplasma gondii infection. We retrospectively analysed 76 infants born to mothers with toxoplasmosis during pregnancy and estimated the risk of mother-to-child transmission considering the gestational age at the time of infection. Seventy-six mothers were given spiramycin, cotrimoxazole and folinic acid; only two babies (2.6%) were infected by Toxoplasma and none of them showed signs or symptoms of congenital infection or interference of sulphamid on tetrahydrofolate reductase (THFR) either at birth or during follow-up. Treatment did not need to be stopped in any mother because of adverse drug effects. Our results seem to encourage the use of spiramycin/cotrimoxazole in women with toxoplasmosis during pregnancy.

Side Effects of the Immune System: Lessons from Tuberculosis-Related Immune Reconstitution Inflammatory Syndrome

Immune reconstitution inflammatory syndrome (IRIS) is a recently described syndrome among human immunodeficiency virus (HIV)-infected patients attributable to the recovery of the immune system during antiretroviral therapy. A growing number of researches on this syndrome have been conducted in recent years, but IRIS in children has not been widely studied. We report the case of a 4.5 month-old, tuberculosis (TB)-HIV co-infected girl who developed IRIS two months after beginning antiretroviral and anti-TB medications. We moreover review the immunopathogenesis of TB-HIV coinfection and IRIS, with particular regard to TB-related IRIS.

Candida albicans endocarditis diagnosed by PCR-based molecular assay in a critically ill pediatric patient

A young Downs syndrome patient developed tricuspid valve endocarditis several years after undergoing surgical closure of a congenital ventricular septal defect. Fungal etiology was established by PCR amplification of the Candida albicans ERG11 gene. Although antifungal therapy was administered, surgical replacement of the infected valve was required to eliminate the infection.

Seizures in an interferon-treated child

Interferon-treated patients can present seizures, which in most paediatric cases are related to fever. The case of chronic hepatitis C is described in which Interferon probably disclosed a latent epilepsy. The hypothesis is advanced that seizures can be provoked by Interferon therapy in subjects with a low convulsant threshold and, in those cases in which it cannot be substituted with another drug, antiepileptic therapy should be started after the first episode.

Health status of internationally adopted children. The experience of an Italian “GLNBI” paediatric centre

Background : according to ISTAT (National Institute of Statistics-Italy), in 2011 20.7% of the foreign population in Italy is composed by children, either coming along with their families or alone, like in international adoptions. Immigrant children have some peculiarities related to their previous living conditions, although there are no significant differences between immigrant and native children’ diseases. Methods : in 3.5 years we evaluated every adoptee that reached our university centre, by using GLNBI (Gruppo di Lavoro Nazionale del Bambino Immigrato) diagnostic – aiding protocol, in order to assess infectious diseases, nutritional deficiencies, immunization status, intestinal parasitosis or other pathologies; this protocol is actually applied only in research centres. Results : we evaluated 358 international adoptees from 4 different Zones of the world; average age at first visit was approximately 5 years. Health certifications concerning vaccination history records were considered “valid” in 59.2% (212/358), 49.5% (105/212) of which had a complete panel of immunization. QuantiFERON®_TB Gold In-Tube (QTF) test resulted negative in 94.0% cases (313/333) and positive in 6.0% (20/333). HIV, HCV and Syphilis tests resulted in 0.3% positive test for each serology (1/358). Cysticercosis’ serology was positive in 8.9% (32/358) using immunoenzymatic assay (not confirmed by immunoblotting) and Toxocariasis in 13.1% (47/358). Parasitological investigation of faeces were found positive on 42.7% (153/358) children, throat swabs in 11.5% (41/358) children. There were 82.4% (295/358) abnormal blood count, 41.9% (150/358) low ferritin, 89.9% (322/358) endocrine abnormalities and 20.4% (73/358) various pathologies evaluated by specialists. Conclusions : pathologies affecting our study group are the same affecting other categories of immigrant children, because they often share similar living conditions as orphanage or crowded residencies, low and poor intake of appropriate nutrients for growing ages, leading to malnutrition, vitamin D deficiency, iron deficiency anaemia and intestinal parasitosis. Vaccination records are often not available or reliable. A similar protocol could therefore be helpfully used as an initial management of children coming from a different setting.

Right to health of immigrant minors in Italy and Europe

Undermined survival is usually the reason to migrate: wars, persecutions, famines, natural calamities are just few examples, as well as cultural, economic, social or religious issues. The diversity of these reasons thus correlates with the extreme variability of migrants typologies and their origin countries. Nowadays it has been reached a sufficient stability of the phenomenon, also testified by the growing number of family unities in Italy and all over the Europe, and by the birth of several children in the welcoming country.

Evaluation of a mathematical model proposed to predict the diagnosis of tuberculosis in children with cervical lymph node enlargement.

Carvalho et al. recently published a probability score-system (Table 1), based on easily obtainable clinical-epidemiological and laboratory information, aimed to predict the diagnosis of tuberculosis (TB) in a child with cervical lymph node enlargement [1]. The model has been obtained from a retrospective analysis of 75 children (16 with TB, 59 with non-tubercular (NTM) lymphadenopathy) less than 16 years of age with a final diagnosis of mycobacterial lymphadenitis who sought care at the TB outpatient clinic of the Institute of Tropical and Infectious Diseases, Spedali Civili, Brescia and at the TB Reference Centre and Laboratory of Villa Marelli Institute, Milan, between January 1999 and January 2009. In this study the presence of abnormal findings on chest radiograph, being foreign born and increasing age were all variables independently associated with TB diagnosis in children with lymphadenitis. The model had a sensitivity of 87.5% and a specificity of 88% when using, as a discriminating cut-off, the estimated probability of TB lymphadenitis 0.22 [1]. This study is of particular interest since the differential diagnosis between TB and NTB lymphadenitis in children is difficult and often requires several biopsies for culture and molecular tests and histologic characterization [2], which often cannot be performed in lowincome high TB and NTB burden countries. Due to the potential implications of this study, we performed a retrospective study involving children less than 16 years of age with a final diagnosis of TB lymphadenitis admitted at the Pediatric Infectious Disease Unit of the Catholic University of the Sacred Heart and at the Infectious Disease Unit of the Bambino Gesù Hospital, both in Rome, between January 1990 and December 2009, intended to evaluate the proposed model. A definitive diagnosis of TB lymphadenitis was based on the presence of a positive culture or a positive polymerase chain reaction (PCR) for Mycobacterium tuberculosis complex species from lymph node specimen (by biopsy or fine needle