Pierangelo Chinello

Saccharomyces cerevisiae fungemia in a neutropenic patient treated with Saccharomyces boulardii

Abstract A case of Saccharomyces fungemia in an 8-month-old baby affected by acute myeloid leukemia while receiving intensive chemotherapy is reported. The patient was receiving prophylaxis treatment with Saccharomyces boulardii capsules (Codex) to prevent diarrhea, which is commonly associated with this type of chemotherapy. Fever spiked just the day after ending the chemotherapy course, and a strain of Saccharomyces cerevisiae was isolated from blood culture although the patient was also receiving antifungal prophylaxis with fluconazole. The patient recovered, though still neutropenic, with amphotericin-B and removal of the central venous catheter. The common biochemical characteristics make it difficult to differentiate between the strain of Saccharomyces cerevisiae and that of Saccharomyces boulardii with routine methods. In other cases, authors demonstrated an identity between the two strains with a more detailed analysis. These reports raise concern about the potential side effects of such biotherapeutic agents.

Early syphilitic hepatitis in an immunocompetent patient : really so uncommon?

The incidence of syphilis has increased substantially over the past years, particularly in men who have sex with men. The clinical manifestations of syphilis are variable and liver involvement is uncommon, but may occur at any stage of the disease. We report a case of early syphilitic hepatitis (ESH) in an immunocompetent patient referring multiple bisexual exposures, who presented at admission with jaundice, tiredness, an ulcerated genital lesion and an increase of liver aminotransferases. During his hospital stay, he developed a skin rash, and serology for syphilis was found positive. Our case report strengthens the need to take into consideration the diagnosis of ESH in all patients with unexplained liver enzyme increase and epidemiological data of unsafe sexual exposures. Indeed, an early recognition of the clinical manifestations of syphilis can lead to a prompt treatment, and allows the prevention of the transmission of this disease to other individuals.

Treatment and outcome of pulmonary arterial hypertension in HIV-infected patients: a review of the literature.

Pulmonary arterial hypertension (PAH) is a life-threatening complication of HIV infection. The prevalence of HIV-associated PAH (HIV-PAH) seems not to be changed over time, regardless of the introduction of highly active antiretroviral therapy (HAART). HIV-PAH treatment is similar to that for all PAH conditions and includes lifestyle modifications, general treatments, and disease-specific treatments. We reviewed the cases of HIV-PAH reported in the Literature in order to evaluate the role of HAART and specific PAH therapy in the prognosis and outcome of HIV-PAH. The research was performed through the PubMed database, by using the following key words: human immunodeficiency virus, AIDS, pulmonary hypertension, antiretroviral, and treatment. The outcome was reported as survival at the end of the observation period of each study. We found 509 patients with HIV-PAH described in the literature to date. At the end of follow-up period, survival rates were 55% and 22% among patients treated or not with antiretroviral therapy (ART), respectively (p = 0.02). Moreover, survival rates at the end of follow-up were 76% and 32% among patients treated or not with specific therapy for PAH (PAH-ST), respectively (p<0.0000001). Survival rates were 69% and 38% among patients treated or not with ART and PAH-ST, respectively (p = 0.02). Specific therapy for PAH should be strongly recommended in patients with HIV-PAH. The role of the HAART in influencing the outcome of HIV-PAH is controversial, even if some evidences seem to indicate a beneficial effect in the clinical course of the disease.

Sildenafil plasma concentrations in two HIV patients with pulmonary hypertension treated with ritonavir-boosted protease inhibitors

Sildenafil is increasingly used for the therapy of pulmonary arterial hypertension (PAH) in HIV infected patients. However, concerns exist about pharmacokinetic interactions between sildenafil and protease inhibitors (PI); in particular, ritonavir has been shown to increase sildenafil AUC and Cmax by several folds. The aim of our study was to determine the plasma levels of sildenafil and PI in two HIV patients with PAH treated with antiretroviral therapy including ritonavir-boosted PI. Our patients both experienced sildenafil Cmax above 500 ng/mL; however, they did not report any significant adverse reactions to sildenafil during the follow-up period. Therapeutic drug monitoring of sildenafil should be taken in consideration during treatment in order to avoid overdosage.

HIV infection and pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a rare but severe disease that results from chronic obstruction of small pulmonary arteries, leading to right ventricular failure and, ultimately, death. One established risk factor for the development of PAH is HIV infection. In comparison with the incidence of idiopathic PAH in the general population (1–2 per million), HIV-infected patients have a 2500-fold increased risk of developing PAH. The presence of PAH is an independent risk factor for mortality in patients with HIV infection, and in most cases death is causally related to PAH rather than to other complications of HIV infection. This article will focus on HIV-PAH with special considerations to epidemiology, pathogenesis, clinical presentation, diagnostic approach and available treatments.

Pulmonary arterial hypertension and HIV infection.

In their recent article on the role of HIV and human herpes virus-8 (HHV-8) infection in pulmonary arterial hypertension (PAH), Hsue et al. [1] found a high prevalence of elevated pulmonary artery systolic pressure (PASP) in HIV-infected persons as compared with HIVnegative controls, suggesting a causal role of HIV in PAH, whereas no association between HHV-8 infection and elevated PASP in HIV-infected individuals was found.

Criteria for discharge of patients with Ebola virus diseases in high-income countries.

During the recent epidemic of Ebola virus disease (EVD) in west Africa,1 several health-care and aid workers infected with EVD were evacuated to Europe and the USA, where local transmission occurred in occupationally exposed health-care workers. Preparation for discharge requires an organised and evidence-based approach to ensure that the patient, health-care workers, family, and community are protected at all times. The risk of infection to others after discharge in the community and of unexpected late clinical events for the patient make discharge policies difficult to formulate.

QTc interval prolongation in HIV-infected patients: a case–control study by 24-hour Holter ECG recording

BackgroundAim of the study was to assess QTc interval by a 24-hour ECG recording in a group of HIV-infected individuals with a basal prolonged QTc. The risk factors associated with QTc prolongation and the indices of cardiovascular autonomic control were also evaluated.MethodsA case–control study was performed using as cases 32 HIV-infected patients with prolonged (>440 msec) QTc interval as assessed by Holter ECG, and as controls 64 HIV-infected subjects with normal QTc interval. Autonomic function was evaluated by heart rate variability analysis during 24-hour recording.ResultsDuration of HIV disease was significantly longer among cases than among controls (p=0.04). Waist/hip ratio was also higher among cases than among controls (p=0.05). Frequency domain analysis showed the absence of physiologic decrease of low frequency (LF) in the night period in both cases and controls. The LF night in cases showed a statistically significant reduction when compared with controls (p=0.007).ConclusionsIn our study group, QTc interval prolongation was associated with a longer duration of HIV infection and with a greater waist/hip ratio. HIV patients with QTc interval prolongation and with a longer duration of HIV infection were more likely to have an impairment of parasympathetic and sympathetic cardiac component.

QT Interval Prolongation and Antiretroviral Treatment: Another Point of Interest

(COLATE) trial [8] indicated that the use of lamivudine in a salvage regimen after virological failure of a lamivudine-containing combination did not provide greater virological benefit than a salvage regimen without lamivudine when the aim is for complete viral suppression is aimed. We demonstrated that 48% of patients for whom an initial regimen of stavudine, lamivudine, and nevirapine failed would have limited options for second-line therapy using the drugs that are available in Thailand; this number increased to 63% among patients with late detection of treatment failure, and decreased to 30% among patients with early detection of treatment failure. To preserve future options for the second-line regimen in patients who experience treatment failure with a stavudine, lamivudine, and nevirapine regimen, the HIV-1 RNA assay is an important tool. This tool, as well as antiretroviral therapy, must be made more accessible in resource-limited environments.

Persistent detection of dengue virus RNA in vaginal secretion of a woman returning from Sri Lanka to Italy, April 2017

We describe the dynamics of dengue virus (DENV) infection in a woman in her mid-30s who developed fever after returning from Sri Lanka to Italy in April 2017. Laboratory testing demonstrated detectable DENV-RNA in plasma, urine, saliva, vaginal secretion. Persistent shedding of DENV-RNA was demonstrated in vaginal secretion, and DENV-RNA was detectable in the pelleted fraction up to 18 days from symptom onset. These findings give new insights into DENV vaginal shedding and vertical transmission.