Roberto Stellini

Methicillin-resistant Staphylococcus aureus ST398, Italy.

To the Editor: It has recently become apparent that livestock can constitute a new methicillin-resistant Staphylococcus aureus (MRSA) reservoir and be a source of a novel and rapidly emerging type of MRSA. These livestock-associated MRSA clones are nontypeable by use of pulsed-field gel electrophoresis with SmaI and belong to sequence type (ST) 398 (1). MRSA ST398 clones account for 20% of all MRSA in the Netherlands (2), but the emergence of such clones has been described worldwide (3). Although ST398 transmission has been reported primarily between animals, persons with occupational exposure to livestock are at higher risk for MRSA carriage than the general population. Even though MRSA ST398 usually causes colonization, several cases of infections of variable clinical relevance, varying from skin and soft tissue infections (4) to endocarditis (5) and pneumonia (6), have been described over the past few years. Most instances of ST398 human carriers have been identified among persons who work at pig farms (7). Data regarding MRSA colonization of dairy farmers are less exhaustive and, to our knowledge, only 1 instance of direct transmission between cattle and humans has been proven. MRSA isolates from cows with subclinical mastitis in 2007 in Hungary were indistinguishable from MRSA isolates from the tonsil swab of a farmer who worked with these animals (8). We report a case of MRSA ST398 invasive disease in a cattle farmer, as well as a case of MRSA ST398 necrotizing fasciitis. In early April 2008, a 52-year-old man was admitted to an intensive care unit in Manerbio, Italy, because of severe sepsis and a large ulcerative and suppurative lesion on the right side of his neck. His medical history was unremarkable. He was a worker at a dairy farm, was obese, and did not report any previous contact with the healthcare system. At the time of hospital admission, he was oriented and cooperative. His temperature was 38.4°C, heart rate was 125 beats per minute, and blood pressure was 165/75 mm Hg. Arterial blood gas analysis showed hypoxemia and mild hypocapnia (PaO2 53 mm Hg and PaCO2 33.8 mm Hg on room air). Leukocyte count was 21,280 cells/μL (81.9% polymorphonuclear cells), and platelet count was 310,000 cells/μL. After blood samples were collected and aggressive surgical debridement of affected tissue was performed, empirical treatment with intravenous teicoplanin and imipenem was started. On the basis of histologic appearance of the intraoperative material and computed tomography scan images, necrotizing fasciitis was diagnosed. Culture of blood and necrotic tissue yielded MRSA. On day 3 after admission, antimicrobial drug therapy was changed to teicoplanin and clindamycin and, on day 7, to linezolid. Fever resolved in 3 days and the patient’s condition progressively improved. The patient was discharged after 31 days of antimicrobial drug therapy. The MRSA isolate was susceptible to all the non–β-lactam antimicrobial drugs tested (excluding tetracycline), carried the staphylococcal cassette chromosome mec type V, and was negative for Panton-Valentine leukocidin (PVL) genes. Multilocus sequence typing and sequence typing of the tandem repeat region of protein A gene (spa typing) showed that the isolate belonged to ST398 and spa type 899, respectively. Some issues are of concern. Although the MRSA isolate was PVL negative, its virulence resembled that of PVL-positive strains. Furthermore, it was resistant to tetracycline, as we expected because oxytetracyclines are the antimicrobial drugs most frequently used in pig and cattle farming (3). The major limitation of our study was that data regarding MRSA colonization of the farm are missing, so cattle-to-human transmission cannot be proven. However, because our patient did not have any other potential risk factor, dairy cows were probably the source of the human infection. In countries where community-acquired MRSA is common, all patients with serious S. aureus infections should be treated for MRSA until antimicrobial susceptibilities are known. Our report suggests that even in countries where community-acquired MRSA is still rare, being a cattle farmer may be considered an indication for early treatment against MRSA. The expanding knowledge of this zoonotic potential may undermine existing nosocomial MRSA control programs. In countries where a search and destroy policy (9) is adopted, such as the Netherlands, pig and cattle farmers may warrant screening and isolation at the time of hospital admission. Nevertheless, the first MRSA ST398 nosocomial outbreak has already been described (10). It is difficult to prevent persons with constant exposure to MRSA in their work or home setting from becoming MRSA carriers. Revisiting policies for the use of antimicrobial drugs on livestock farms, as well as improving hygiene measures, may therefore be necessary in infection control programs. However, before final recommendations can be made, further investigation is needed to determine the prevalence of MRSA among livestock and their handlers.

Fatal invasive aspergillosis during cyclosporine and steroids treatment for Crohn's disease.

To The Editor: In recent years cyclosporine has largely replaced azathioprine as the leading immunosuppressive agent and has been used in the treatment of severe inflammatory bowel disease (1-3). So far only one opportunistic infection (Pneumocvstis carinii pneumonia) has been reported in a patient undergoing therapy with 500 mg of cyclosporine and 30 mg of prednisone per day for ulcerative colitis (4). We report a case of invasive aspergillosis pneumonia that affected a woman with Crohns disease during treatment with cyctosporine. A 36-year-old woman, on maintenance therapy with 5-aminosalicylate and prednisone (15 rag/day), was treated, due to clinical and endoscopic deterioration, with 40 mg of prednisone per day for 15 days, followed by 80 mg of methylprednisotone per day for seven days. Her symptoms persisted and intravenous cyclosporine 4 mg/kg body weight per day was added. After 15 days, fever, dyspnea, and chest pain developed; the chest radiography showed pulmonary infiltrates, and bronchoscopic lavage and biopsy were positive for Aspelgillus fumigatus. The patient was admitted to the Department of Infectious Diseases: her temperature was 38.5 ° C, the pulse 108, white cell count 6.2 x 109/liter, lactic dehydrogenase 1960 units/liter (normal 110-210), pH 7.3, Pao 2 55 mm Hg, Paco 2 34 mm Hg, HCO 3 20 mmol/liter. Cyclosporine was discontinued, amphotericin B and flucytosine were given, but the patient died after five days. The patient had received a combination therapy (cyclosporine and steroids), therefore it is difficult to determine that cyclosporine is solely responsible for the immunodepression; however, our case and the other one reported in the literature draw attention to the possibility of an increase of opportunistic infections during cyclosporine therapy in severe inflammatory bowel disease.

Restriction of T‐cell receptor repertoires in idiopathic CD4+ lymphocytopenia

We report that α/β and γ/δ T‐cell repertoires of three patients with idiopathic CD4+ lymphocytopenia, who showed different clinical manifestations and outcomes over time, were highly restricted. The disruption of T‐cell repertoires does not influence the susceptibility to infections: the first patient was unable to attain a protective response to mycobacterium, the second showed clinical improvement and the third did not develop opportunistic infections. These results indicate that idiopathic CD4+ lymphocytopenia could give rise to mono‐/oligoclonal T‐cell expansions, but the degree of repertoire disturbance is not indicative of the severity of disease progression.

Fatal Disseminated Toxoplasmosis During Primary HIV Infection

Toxoplasmosis is a well recognized manifestation of AIDS, but the disseminated disease is a rare condition and it has not been associated to HIV seroconversion to our knowledge. We describe a fatal episode of disseminated T. gondii acute infection with massive organ involvement during primary HIV infection. The serological data demonstrate primary T. gondii infection. The avidity index for HIV antibodies supports recent HIV-1 infection.

Acute lymphoblastic leukaemia of B cell origin in an anti-HIV positive intravenous drug abuser.

karyorrhexis in the marrow, is observed. PNH-tests are again negative. This case shows that the same mechanisms can induce pancytopenia in aplastic anaemia and MDS. Both may respond to ALG. This treatment will not change the course of the leukaemic disease but allows the patient to improve his pancytopenia and to become independent of transfusions. It would be tempting to try ALG in a ‘de novo’ MDS with symptomatic pancytopenia, when BMT is not feasible.

HLA ANTIGENS AND THROMBOCYTOPENIA IN HIV SEROPOSITIVE SUBJECTS

Murphy et a l ( l98 7) reported on the incidence of neutropenia and thrombocytopenia in HIV infected homosexual men. The absence of thrombocytopenia among asymptomatic anti-HIV positive subjects is at variance with our experience as well as with data from the literature (Morris et al, 1982: Savona et al, 1985; Abrams et a1 1986). Among the 503 seropositive subjects screened at our Institution between January 1985 and December 1986. 44 cases of isolated thrombocytopenia (IT) (platelet count < 100 x 109/1) were detected. Furthermore. thrombocytopenia in association with neutropenia (neutrophil count < 1.5 x 109/1) and/or anaemia (haemoglobin < 10 g/l) was found in 14 subjects. The two groups of patients markedly differed in their distribution among the groups of CDC classification of HIV related disease (Table I). The majority of

023 CURRENT TRENDS IN INFECTIVE ENDOCARDITIS IN ITALY: REPORT ON 852 CASES FROM THE MULTICENTER, PROSPECTIVE SEI STUDY

and pulmonary and rheumatologic presentations were more frequent in Group I, whereas in Group II cardiac and abdominal presentations were more common. During hospitalization, septic shock (12.7% vs 18.9%; p = 0.021) was observed more frequently in Group II. There were no differences in periannular complications, heart failure, valvular dysfunction, persistent infection and embolism. In Group II the need of cardiac surgery was higher than in Group I (49.3 vs 58.7%; p 0.011). No differences were observed in hospital mortality (28.1% vs 28%). Conclusions: In the last years the incidence of infective endocarditis was higher in older patients with a higher degree of comorbidity. Prosthetic valve IE increased and IE in IVDU was less frequent. The need for cardiac surgery has also increased. Mortality remained similar.

Clinical Care of Hematological Patients in a Bone Marrow Transplant Unit: Do Human Resources Influence Infection Incidence?

1. Mitchell BG, Dancer SJ, Anderson M, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect 2015;91:211–217. 2. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006; 166:1945–1951. 3. Clifford R, Sparks M, Hosford E, et al. Correlating cleaning thoroughness with effectiveness and briefly intervening to affect cleaning outcomes: how clean is cleaned? PLoS One 2016;11: e0155779. doi: 10.1371/journal.pone.0155779. 4. Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol 2008;29:593–599. 5. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrugresistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet 2017;389:805–814.

Abdominal aortitis and aneurysm impending rupture during pneumococcal meningitis

A 77-year-old woman presented to our emergency department in Brescia, Italy with fever, altered conscious state, and neck stiff ness. She was a heavy smoker, with hypertension and dyslipidaemia, and had had right-sided back pain for the previous 3 days. Head CT and chest radiograph were normal, whereas lumbar puncture and blood cultures revealed pneumococcal meningitis with bacteraemia. Antibiotic therapy with ceftriaxone (2 g twice daily) was started. The patient rapidly improved, with resolution of fever and substantial reduction of infl ammatory markers (white blood cell count dropped from 19·7 cells per mL to 14·9 cells per mL, and C-reactive protein dropped from 225 mg/L to 108 mg/L). However, 12 days after the patient was admitted to hospital, and less than a week after the initial clinical and biochemical improvement, she reported worsening backache , and the infl ammatory markers rebounded (white blood cell count to 19·8 cells per mL and C-reactive protein to 171 mg/L). Lumbar spine CT showed no signs of spondylodiscitis, but an enlarged abdominal aorta with signs of perianeurysmal infl am mation. The CT angiography done straight afterwards confi rmed the presence of an abdominal aortic aneurysm with signs of impending rupture (fi gure A). Mycotic aneurysm and microbial aortitis are un common entities that usually occur in people with under lying atherosclerotic vascular disease as a consequence of bacteraemic seeding on the abnormal aortic surface. The clinical presentation is often subacute, and the diagnosis often delayed or not made until after death. Streptococcus pneumoniae, despite being a common cause of bacteraemia, is seldom responsible for vascular seeding. Yet, pneumococcal aortitis should be ruled out in patients with sepsis at high risk of cardiovascular diseases presenting with typical symptoms of abdominal aortic aneurysm. The patient promptly underwent aorto-aortic homograft substitution. The patient recovered after surgery without any complications and returned home shortly thereafter. CT angiography done after 1 month, however, revealed the presence of an initial disease progression (fi gure B), but the patient refused any surgery. Since then, she has had strict clinical and radiological follow-up examinations without evidence of further worsening. After almost 12 months she is still alive and in a good clinical condition.