Roberto Luzzati

Nosocomial epidemic of active tuberculosis among HIV-infected patients.

In an investigation of a nosocomial outbreak of tuberculosis, 18 HIV-infected inpatients were found to have been exposed to Mycobacterium tuberculosis; active tuberculosis developed in 8, 7 within 60 days of diagnosis of the index case. The patients with lower total lymphocyte and CD4 lymphocyte counts were more likely to get the disease than were those with higher counts. A low score on multiple antigen skin testing was also associated with the development of active tuberculosis. 4 of the 18 patients had a positive tuberculin skin test before exposure to M tuberculosis; none of them subsequently got the disease.

Nosocomial Candidemia in Non-Neutropenic Patients at an Italian Tertiary Care Hospital

Abstract In a retrospective study conducted in an Italian tertiary care hospital, the incidence of nosocomial candidemia was evaluated together with causative pathogens, treatment, and risk factors for death. Over a 6-year period (1992–1997), a total of 189 episodes of candidemia occurred in 189 patients (mean age 58±19 years), accounting for an average incidence of 1.14 episodes per 10,000 patient-days per year. The most common reasons for hospitalization were solid neoplasia (21%), trauma (17%), abdominal diseases requiring surgery (13%), and cardiovascular diseases (13%). No patient was neutropenic within 3 weeks prior to the onset of candidemia. One hundred thirty patients were hospitalized in intensive care units, 47 patients in surgical wards, and 12 patients in medical wards. Candida albicans was the most frequently isolated pathogen, accounting for 54% of fungal isolates, followed by Candida parapsilosis (23%), Candida glabrata (7%), Candida tropicalis (5%), Candida pelliculosa (4%), Candida lusitaniae (1%), Candida humicula (1%), and other non-albicans Candida spp. (5%). Seventy-six (41%) patients received adequate antifungal therapy. Seventy-one (58%) of the 123 evaluable patients with central venous catheters underwent line removal; 51 of them had catheter-related candidemia. The 30-day crude mortality rate was 45%. Older age, hospitalization in an intensive care unit, a longer duration of candidemia, retention of central lines, and inadequate antifungal therapy were significantly associated with poor outcome. In the present study, nosocomial candidemia was a frequent and relatively underestimated illness. Adequate antifungal therapy and central line removal independently reduced the high mortality of the disease.

Riboflavine and severe lactic acidosis

taken and respiratory function tests were done. CC16 plasma serum concentrations were measured by a sensitive immunoassay that has been validated with an alternate m e t h o d and is based on the agglutination of latex particles coated with polyclonal antiCC16 antibodies. Cystatin C, a small protein like CC16, was measured in serum to detect possible variations in the glomerular filtration rate, a potential confounder for CC16 concentrations. After the ride, serum concentration of CC16 was significantly higher in men (12·3 [SD 0·9] v s 11·2 [0·8] g/L, p=0·011, paired-samples Student’s t test) and women (11·9 [1·3] v s 11·1 [0·6] g/L, p=0·012). Stepwise regression analysis showed that the increase in serum CC16 after the run was independent of sex and variations in the serum cystatine C, but correlated with the O3 concentrations (r =0·18, p=0·0024). A more significant correlation was found between O3 concentrations and the concentrations of CC16 in serum (r =0·29, p<0·0001) after the ride (figure). Lung function before and after the ride (paired-samples Student’s t test) showed no significant change in FEV1 and FVC, which are usually impaired by O3. We found increased airway permeability in moderately exercising participants exposed on average to 0·07 ppm O3 over 2 h. Our observations indicate that air pollutants can produce effects on the pulmonary epithelium that are underestimated or undetected with the usual tests.

Diagnosis, management and outcome of clinically- suspected spinal infection.

OBJECTIVES Spontaneous spinal infection (SI) is a quite rare but serious entity. This study aimed to evaluate outcome and follow-up data of SI cases without a microbiological diagnosis (suspected SI). METHODS We undertook a retrospective, comparative study of 82 spontaneous SI cases in adults presenting over an 11-year period to two Italian hospitals. RESULTS The diagnostic yields of blood culture, percutaneous needle biopsy of spine, and surgical sample culture were 43.6%, 72.7%, and 91.6%, respectively. Overall, causative organisms were identified in 60 (73.2%) cases, the most frequently isolated pathogens being Staphylococcus aureus and Mycobacterium tuberculosis. The median diagnostic delay was similar (p=0.39) in pyogenic (1 month) and suspected (0.5 month) SI cases, and longer in tuberculous cases (4 months) than in the other SI case groups (p=0.069 and p=0.062, respectively). All patients received antibiotic treatment, and 21 (25.5%) underwent surgery, that was required more frequently in tuberculous (40.7%) than in pyogenic (25.0%) and suspected SI cases (9.1%) (p=0.028). Of 67 patients who completed a 1-year follow-up period, 24 had persisting painful disability that was more frequent in tuberculous (66.7%) cases than in pyogenic (21.7%) and suspected SI (15.0%) cases (p=0.03). CONCLUSIONS Although a microbiological diagnosis was not achieved in nearly a quarter of SI cases, both diagnostic delay and outcome were similar to those of pyogenic SI cases. Earlier recognition of tuberculous SI is mandatory, as this is associated with the highest long-term morbidity.

Peripheral and total parenteral nutrition as the strongest risk factors for nosocomial candidemia in elderly patients: a matched case–control study

Candidemia is an important cause of morbidity and mortality in the healthcare setting. However, there is limited information about risk factors for such infection among elderly patients. A case–control study was conducted during the period 2008–2011. For each case, two controls were selected among patients admitted to the same hospital, and individually matched by sex, age, time of admission, hospital ward and hospitalisation duration. The adjusted odds ratio (OR) was calculated using multiple conditional logistic regression. We identified 145 episodes of candidemia occurring in 140 patients with a median age of 80 years. Candida albicans caused 55% of all candidemia episodes. After adjustment, candidemia was strongly associated with duration of total [duration > 7 days: OR = 20.09; 95% confidence interval (CI): 3.44–117.52] and peripheral parenteral nutrition (duration > 7 days: OR = 26.83; 95% CI: 6.54–110.17), other central vascular catheters (OR = 5.17; 95% CI: 1.24–23.54) and glycopeptide antibiotics (OR = 6.45; 95% CI: 1.90–21.91). Duration of peripheral and total parenteral nutrition and antibiotics predicted over 50% of all candidemias. Intervention studies should be planned to evaluate effectiveness of candidemia prevention by restricting parenteral nutrition, prompting earlier enteral feeding, and reducing use of antibiotics, especially glycopeptides, in elderly patients.

Cryptococcal Meningitis and Intracranial Tuberculoma in a Patient with Waldenstrom's Macroglobulinemia Treated with Fludarabine

We report a patient with Waldenstroms Macroglobulinemia who presented with cryptococcal meningitis followed by an intracranial tuberculoma during the 18 months period after termination of cytotoxic therapy with Fludarabine. Opportunistic infections due to intracellular organisms are extremely rare in the course of this malignancy and we review the predisposing factors of these infectious entities.

Computerized tomography and magnetic resonance guided stereotactic brain biopsy in nonimmunocompromised and AIDS patients.

BACKGROUND The utility of stereotactic brain biopsy (SBB) in AIDS patients still remains controversial. The authors investigated SBB-related diagnostic accuracy, complications, and postoperative sequelae in nonimmunocompromised (NIC) patients and AIDS patients. The role of bioptic yield in treatment planning was also studied in AIDS patients. METHODS From 1990-95, 200 computerized tomography (CT) or magnetic resonance imaging (MRI)-guided SBBs were performed in our Department; 172 bioptic procedures were performed in NIC patients (169), and 28 SBBs in AIDS patients (27). The statistical significance was evaluated using the Fisher exact t-test. RESULTS SBB accuracy was very high in both NIC (94.8%) and AIDS (92.9%) patients. Statistical analysis indicated nonsignificant (NS) differences between the two study groups (P > 0.05). Diagnostic yield resulted higher in contrast-enhancing (CE) brain lesions (98.6% in NIC and 95.0% in AIDS patients; P > 0.05; NS), than in non-CE lesions (74.1% in NIC and 87.5% in AIDS patients; P > 0.05; NS). The overall complication rate was similar in both groups (17.2% in NIC and 14.8% in AIDS patients, P > 0.05, NS). The most frequent complication was hemorrhage, with statistically negligible differences between the two study groups (P > 0.05). The frequency of complications involving minor/major morbidity or mortality was very low in NIC (5.9%, 0.6%, and 2.4%, respectively), and in AIDS (3.7%, 7.4%, and 0.0%, respectively) patients. Regarding the therapeutic impact of bioptic diagnosis for neuro-AIDS patients, the preoperative treatment attitude was modified in 23/27 cases (85.2%), and the empiric anti-toxoplasmosis regimen was changed or withdrawn in 17/21 patients (81.0%). CONCLUSION Our experience demonstrated SBB to be an accurate, manageable, and reasonably safe diagnostic tool in both NIC and AIDS patients. These results suggest also that timely SBB indication in selected AIDS patients, reaching an early diagnosis, may on one side prevent unnecessary and potentially toxic empiric therapeutic regimens, and on the other address the appropriate treatment, thereby improving length and quality of life in such patients.

Gamma knife radiosurgery in AIDS-related primary central nervous system lymphoma

The frequency of AIDS-associated primary central nervous system (PCNS) lymphoma is rapidly increasing in adults and children. In AIDS-related PCNS lymphoma, different authors have reported an overall poorer response rate to conventional radiation compared with immunocompetent patients. This poorer response consists of a significantly positive, although transient effect on survival following radiotherapy (XRT), with a poor toleration for prolonged whole-brain RT (WBR) and with radiation-induced changes within the normal CNS tissue on autopsy examinations after a course of XRT. These observations led us to consider highly focused single-session radiosurgical treatments as a potentially useful therapeutic modality for AIDS-associated PCNS lymphomas. A multi-institutional diagnostic and therapeutic protocol for the evaluation and treatment of AIDS patients with high-risk intracerebral space-occupying lesions has been developed at the University Hospital of Verona. Therapy is based on tumor biopsy. Tumors < or = 3.5 cm in diameter are subjected to Gamma Knife radiosurgery, whereas tumors < or = 4.5 cm are treated with stereotactic brachytherapy. At the Department of Neurosurgery, Verona, Italy, Gamma Knife treatment was performed in 2 cases of deep-seated histologically verified malignant non-Hodgkins lymphoma. A short-term cliniconeuroradiological follow-up (2 months later) showed neurologic improvement and virtually complete disappearance of the tumor in both patients. The excellent local control and the well-tolerated single-session treatment and absence of brain toxicity signs on CT scan indicate a putative role for Gamma Knife radiosurgery in the treatment of these patients.

Prevalence of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infections Among Transgender Persons Referred to an Italian Center for Total Sex Reassignment Surgery

Introduction The burden of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in transgender population is an underestimated issue. We performed a study to evaluate the prevalence of such infections in transgender persons addressed our center for total sex reassignment surgery (SRS). Materials and Methods All transgender persons undergoing SRS from 2000 to 2014 were evaluated retrospectively. Participant characteristics and results of HIV, HBV, and HCV testing were collected. Exact Fisher test, Cochran-Armitage tests for trend and correct prevalence ratios were estimated. Results Among 498 transgender persons, 243 had confirmed serological data. Of them, 25 were female-to-male and 218 male-to-female (MtF) subjects. The prevalence of HIV, HBV and HCV infections was 0%, 4.0%, and 8.0% in female-to-male, and 12.1%, 4.6%, and 3.7% in MtF. Among MtF, younger age and earlier year of SRS were associated with lower HIV prevalence. From the multivariate model, the mutually adjustment prevalence ratios were 1.9 (95% confidence interval [95% CI], 1.2–3.1) for SRS in 2005–2010 and 3.6 (95% CI, 1.3–9.4) in 2010–2014, as compared with SRS in 2000–2004; and 4.7 (95% CI, 2.4–9.4) for South Americans as compared with others. Among the HCV-positive MtF, 57.1% were also HIV-positive. Regarding HBV, the immunity was 38.5% and, after mutual adjustment, the prevalence ratios were 2.1 (95% CI, 1.3–3.4) for South Americans versus others and 2.2 (95% CI, 1.6–3.1) for year of birth ≥ 1980. Discussion The prevalence of HBV and HCV infections among our transgender persons overlaps that reported in the general population, but HCV prevalence was much higher in HIV-infected MtF. The high burden of HIV infection among MtF and its recent incremented prevalence points out that social and medical support should be strongly promoted in such population.

Removal of Central Venous Catheters from Patients with Candidemia

Sir—We read with interest the recent article “Should Vascular Catheters Be Removed from All Patients with Candidemia? An Evidence-Based Review” by Nucci and Anaissie [1], who attempt to clarify a controversial issue related to the clinical management of this infection. As the authors of a study [2] cited in their article, we were surprised by the interpretation of some of our data, and we would like to add our comments on this topic. First, in our retrospective study [2], removal of central venous catheters (CVCs) was associated with a significant decrease in the mortality rate (OR, 0.62; 95% CI, 0.38–0.99; ). The mortality rate P p .047