Serafino Mansueto

Epidemiological trend of human leptospirosis in Italy between 1994 and 1996

In the three-year period 1994–1996, 222 reports on human cases of leptospirosis were received by the Italian Ministry of Health. The average annual number of reports was 29.2% lower than in the preceding eight years. In all cases but two the infections were thought to have been acquired in Italy. As in previous years, the majority of cases was observed in the northern regions of the country (83.8%), mostly in males (88.9%). Cases occurred in all age groups, but were more common in the working-age population (15–64 years). There was no common-source outbreaks. The typical leptospiral seasonal course, with a peak in August, was observed. During 1994, leptospirosis was the reported cause of death in 19 patients. Mortality was higher among males than females. The overall fatality rate was 22.6%. During the study period, a total of 126 cases of leptospirosis were confirmed by the National Centre for Leptospirosis or one of the 12 Regional Leptospira Laboratories. Of the 103 patients for whom information on place of residence, contact with animals, occupational and recreational activities was available, 98 (95.1%) were people who live in rural areas or devote themselves to occupational or recreational activities at risk. The likely source of infection and the mode of exposure were known for 55 patients. Forty-five patients (81.8%) were likely infected by contaminating water (43 cases) or soil (2 cases), ten (18.2%) by direct contact with animals or animal urine. Both running (51.2%) and stagnant water (27.9%) have been reported as a source of infection. Rodents were implicated in 50.0% of the 10 cases involving animals. In comparison with the preceding eight-year period, the risk of contracting leptospirosis was found to have increased for recreational activities (from 34.7 to 38.2%) and decreased for occupational activities (from 45.8 to 32.7%). A large number of infections, however, was ascribed to accidental events (25.5%). As in the previous period, besides fever, the involvement of the liver was the most frequent clinical manifestation (70.8%). Influenza-like symptoms were the only signs of illness in 15.1% of cases. Infections by 9 different serogroups were detected. The most frequent antibodies were those against serovars icterohaemorrhagiae, poi, copenhageni and bratislava. The presence of co-agglutinins against serovars belonging to different serogroups prevented the identification of the presumptive infecting serogroup in 19.8% of subjects.

Pathogenesis of rickettsial eschars: The tache noire of boutonneuse fever

Prospective investigation of cutaneous lesions of 24 Sicilian patients revealed that 17 were taches noires from patients with a documented diagnosis of boutonneuse fever. Immunofluorescent Rickettsia conorii were demonstrated in 14 of 17 taches noires. The major pathologic lesions observed were a moderate-to-severe lymphohistiocytic vasculitis (17 of 17 cases), generally moderate dermal edema (17 of 17 cases), and cutaneous necrosis (12 of 16 cases). In contrast with previous observations of eschars in Rocky Mountain spotted fever, thrombosis was usually absent (nine of 17 cases) or inconsequential (five of 17 cases). Thus, it appears that the pathogenic mechanism of the ischemic necrosis is not thrombosis, suggesting either compression of the microcirculation by the dermal edema or another mechanism. Review of the biomedical literature related to eschars and cutaneous arthropod bites strongly argues against a pathogenetic contribution of the tick bite itself other than the intradermal inoculation of rickettsiae. The tache noire offers an excellent, accessible model for the study of the human-rickettsia interaction, including the pathogenic mechanisms leading to necrosis and the immune mechanisms resulting in killing the rickettsiae.

Immunopathology of leishmaniasis: an update.

Leishmaniasis represents a severe, increasing, public health problem. The perspective of its control is highly dependent on research progress, on therapeutic manipulations of the immune system, and on vaccine development. There is a correlation between the clinical outcome of Leishmania infection and the cytokine response profile. While a protective immune response against Leishmania has been clearly identified to be related to the influence of a type-1 response and IFN-γ production, the precise role of T helper (TH) 2 cytokines in non-healing infections requires further exploration. IL-4 and IL-13 (TH2 cytokines) can promote disease progression in cutaneous leishmaniasis, whereas IL-4 would appear to enhance protective type-1 responses in visceral leishmaniasis. Thus, the TH1/TH2 paradigm of resistance/susceptibility to intracellular parasites is probably an oversimplification of a more complicated network of regulatory/counter regulatory interactions. Moreover, the presence of antigen specific regulatory T cell subsets may provide an environment that contributes to the balance between TH1 and TH2 cells. Finally, the involvement of CD8+ T cells has been described, but the modality of their function in this kind of infection has not been so far elucidated.

Survey on the prevalence of leptospira infections in the Italian population

This investigation is the first nationwide survey on the circulation of leptospira infections in human beings in Italy. In nine out of twenty Italian regions, representative samples of the population were investigated for the presence of leptospira infections. Unexpectedly, leptospira infections were found to be widespread, the number of cases being much higher than the diagnosed clinical cases. There were found to be high, medium, and low risk areas. On the whole, the risk for the rural population was no higher than the risk for urban dwellers; leisure activities, contact with animals and residence on the plain versus residence in the hills were important risk factors. There was an unidentified risk factor in urbanites which was absent in the rural population. A changing pattern in infecting serovars was observed, with infections from serogroups Sejroe, Javanica and Australis prevailing over infections from the Icterohaemorrhagiae and Bataviae serogroups, which were the main agents of human leptospirosis during the 1950s. The mechanisms of these changes, the need for epidemiological surveys and improved diagnostic methods of screening are discussed.

A sero-epidemiological survey of asymptomatic cases of boutonneuse fever in western Sicily

963 sera from contacts, persons from various localities, and blood donors were examined with a commercially produced kit for micro-immunofluorescence for the presence of antibodies to Rickettsia conorii. 10.6% of sera were serologically positive. The higher rates of positivity were observed in sera of contacts (19%) and persons from Mussomeli (20%) and Ustica (18.4%), the lower rates in blood donors from Palermo (3.5%). These results support the view that there is an occupational risk factor related to a rural environment.

Presence of Rickettsia conorii subsp. israelensis, the Causative Agent of Israeli Spotted Fever, in Sicily, Italy, Ascertained in a Retrospective Study

ABSTRACT A retrospective analysis by molecular-sequence-based techniques was performed to correctly identify the etiological agent of 24 Mediterranean spotted fever cases occurring in Western Sicily, Italy, from 1987 to 2001. Restriction analysis of a 632-bp PCR-amplified portion of the ompA gene allowed presumptive identification of five clinical isolates as belonging to Rickettsia conorii subsp. israelensis, the etiological agent of Israeli spotted fever (ISF). The remaining 19 rickettsial isolates were Rickettsia conorii subsp. conorii, the only pathogenic rickettsia of the spotted fever group reported in Italy until the present. Sequence analysis of the ompA gene confirmed the identification of all the R. conorii subsp. israelensis isolates and demonstrated that rickettsiosis caused by R. conorii subsp. israelensis can be traced back to 1991 in Sicily. The recorded clinical data of the five ISF patients support the idea that these strains could correlate to more-severe forms of human disease. Three of five patients experienced severe disease, and one of them died.

The histology of “taches noires” of boutonneuse fever and demonstration ofRickettsia conorii in them by immunofluorescence

The recent increase in the incidence of boutonneuse fever in Italy provided the opportunity to study the pathology of six “taches noires,” the lesions at the site of tick bite. The center of the lesion has either an ulcer or an area of necrosis of the epidermis and superficial dermis; in some cases the epidermis is intact. The alterations are mainly in the dermis and subcutaneous tissues where the small vessels show endothelial swelling and intramural and perivascular oedema and inflammation with macrophages, lymphocytes and smaller numbers of plasma cells, PMNs and eosinophils. In a few small arteries and fewer veins there are either nonocclusive mural or occlusive thrombi; there is no spatial or quantitative correlation between thrombosis and necrosis. We propose that cutaneous necrosis results from severe injury to many small vessels. Rickettsiae which had not been previously observed in “taches noires” were demonstrated in blood vessels by immunofluorescence, a finding that may be used as a means for early aetiological diagnosis of the disease. The “tache noire” is an excellent human model for localized rickettsial injury.

CD4+ CCR5+ and CD4+ CCR3+ lymphocyte subset and monocyte apoptosis in patients with acute visceral leishmaniasis

The potential involvement of apoptosis in the pathogenesis of visceral leishmaniasis (VL) was examined by studying spontaneous and Leishmania antigen (LAg)‐induced apoptosis using cryopreserved peripheral blood mononuclear cells (PBMC) of Sicilian patients with VL. Results indicate that monocytes and T lymphocytes from acute VL patients show a significantly higher level of apoptosis compared with that observed in healed subjects. The percentage of apoptotic cells was higher in monocytes than in T lymphocytes. T cells involved in programmed cell death (PCD) were mainly of the CD4+ phenotype. In particular, the T helper 1‐type (Th1) subset, as evaluated by chemokine receptor‐5 (CCR5) expression, is involved in this process. Cell death in Th1‐type uses a CD95‐mediated mechanism. Furthermore, Th1‐type CCR5+ cells are prone to cell suicide in an autocrine or paracrine way, as attested by enhanced expression of CD95L in acute VL patients. The reduction in Th1‐type cells by apoptosis was confirmed by the decrease in interferon‐γ secretion. In conclusion, apoptosis of monocytes, CD4+ and CD4+ CCR5+ T cells could be involved in the failure of cell mediated immunity that is responsible for severe immune‐depression in VL.

Role of TLR4 receptor polymorphisms in Boutonneuse fever.

The genetics of the interaction between host and microbes plays an essential role in the survival of the individual and attainment of longevity. The activation of toll-like receptor (TLR)4 plays a key role in natural and clonotypic immune responses. We evaluated whether TLR4 genotype is a component of genetic background protective versus rickettsiosis and whether this background influences longevity. We genotyped for +896A/G TLR4 polymorphism 78 patients affected by Boutonneuse fever, 78 age-matched controls and 78 advanced age individuals from Sicily. The +869G allele, that attenuates receptor signalling, was significantly overrepresented in patients in comparison with age-matched controls. By analyzing data according to gender, this allele was significantly higher in female patients when compared to advanced age women. Pro-inflammatory responses are programmed to resist fatal infections. So, it is not surprising that the genetic background of people that survive to an advanced age may be protective against infections. However, this seems to occur in women but not in men. In a previous study, the +896G TLR4 allele was overrepresented in advanced age men and underrepresented in men affected by myocardial infarction. Thus, previous and present results tend to agree with the suggestion that men and women may follow different trajectories to reach longevity. For men it might be more important to control atherogenesis, whereas for women it might be more important to control infectious diseases.

Serum levels of soluble CD23 in patients with asthma or rhinitis monosensitive to Parietaria. Its relation to total serum IgE levels and eosinophil cationic protein during and out of the pollen season.

The diagnostic value for allergies of the low affinity IgE receptor and its soluble circulating fragment (sCD23) remains unclear. In particular, little is know about seasonal influences on serum sCD23 levels in subjects with pollen allergy. In the present study, to gain insight into pathophysiological role of sCD23, we have analyzed, in blood from patients allergic to Parietaria sCD23, IgE, and eosinophil cationic protein (ECP) serum levels. IgE were assessed as atopy markers and ECP as an inflammation marker. Patients were studied during and out of pollen season, and results were compared to those obtained in nonallergic subjects. The study population included 42 nonsmoking outpatients, living in Palermo (Sicily, Italy) or in other west Sicilian towns, with a clinical diagnosis of seasonal asthma or rhinitis and monopositive skin test to Parietaria pollen. The group of asthmatic subjects consisted of 25 patients who had one or more of the usual asthma symptoms (wheezing, dyspnea, and cough) only during the pollen season. The group of rhinitis patients consisted of 17 patients, who, during pollen season, had the nasal symptoms (nasal blockage, sneezing, nasal itching, and rhinorrhoea) but no signs of asthma. As a control group, we studied 10 nonatopic subjects from laboratory staff. They had no history of seasonal or perennial rhinitis, asthma, or urticaria and had negative skin tests to a panel of allergens. Soluble CD23, IgE, and ECP were assessed in blood during and out of pollen season. Total serum IgE levels were clearly higher in atopic patients, as classically established. Concerning sCD23 serum levels, a similar pattern of results was obtained. Accordingly, significant correlations were shown between the levels of sCD23 and IgE in all groups of patients. A completely different pattern was observed by analyzing serum ECP levels because ECP levels were significantly increased only in asthmatic patients during pollen season. Accordingly, no significant correlations were observed between the levels of sCD23 and those of ECP. Identifying immune factors associated with the development of atopy can enhance our understanding of the in vivo mechanisms involved and may have utility in paradigms designed to prevent diseases. As demonstrated by the close correlation with total serum IgE values and the lack of correlation with serum ECP values, serum levels of sCD23 appear to be an additional marker for the diagnosis of atopy but not for the follow-up of allergic diseases.