Valeria Gaspari

Neutrophilic Figurate Erythema of Infancy

Abstract:  We report here a new case of neutrophilic figurate erythema of infancy in a 1‐year and 9‐month‐old white boy. Neutrophilic figurate erythema of infancy is a rare inflammatory dermatosis which is part of the figurate inflammatory dermatoses of infancy and is considered a variant of annular erythema of infancy. The disease is clinically characterized by annular erythematous lesions, sometimes with a polycyclic configuration, and histologically by a dermal neutrophilic infiltration with leukocytoclasia. Differential diagnosis mainly includes clear‐cut severe diseases with a well‐known etiology, such as neonatal lupus erythematosus and its variant erythema gyratum atrophicans transiens neonatale, erythema chronicum migrans and erythema marginatum rheumaticum, and diseases of unknown origin and with less clear limits, such as erythema annulare centrifugum and its variant familial annular erythema. Anamnesis, laboratory findings, clinical features, and histology allow the correct diagnosis and therefore, having excluded severe diseases, parents should be reassured as neutrophilic figurate erythema of infancy, as the annular erythema of infancy, is a benign disease, in most cases unassociated with other conditions and usually self‐limiting over a few months, even though a chronic course may rarely occur. Our case was characterized by a chronic persistent course and by a complete resolution of the lesions only during febrile episodes.

Enhanced molecular typing of treponema pallidum subspecies pallidum strains from 4 Italian hospitals shows geographical differences in strain type heterogeneity, widespread resistance to macrolides, and lack of mutations associated with doxycycline resistance

Background Although syphilis rates have been relatively high in Italy for more than 15 years, no data on the molecular types of Treponema pallidum subspecies pallidum circulating in this country are yet available. Likewise, no data on how widespread is resistance to macrolide or tetracycline antibiotics in these strains exist. Such data would, however, promote comprehensive studies on the molecular epidemiology of syphilis infections in Italy and inform future interventions aiming at syphilis control in this and other European countries. Goals and Study Design Swabs from oral, genital, cutaneous, or anal lesions were obtained from 60 syphilis patients attending dermatology clinics in Milan, Turin, Genoa, and Bologna. Molecular typing of T. pallidum DNA was performed to provide a snapshot of the genetic diversity of strains circulating in Northern Italy. Samples were also screened for mutations conferring resistance to macrolides and tetracyclines. Results T. pallidum DNA was detected in 88.3% (53/60) of the specimens analyzed. Complete and partial T. pallidum typing data were obtained for 77.3% (41/53) and 15.0% (8/53) of samples, respectively, whereas 4 samples could not be typed despite T. pallidum DNA being detected. The highest strain type heterogeneity was seen in samples from Bologna and Milan, followed by Genoa. Minimal diversity was detected in samples from Turin, despite the highest number of typeable samples collected there. Resistance to macrolides was detected in 94.3% (50/53) of the strains, but no known mutations associated with tetracycline resistance were found. Conclusions Genetic diversity among T. pallidum strains circulating in Northern Italy varies significantly among geographical areas regardless of physical distance. Resistance to macrolides is widespread.

Pedunculated nodule on an infant's face.

Case Report An 11-year-old Caucasian boy with good general health and normal development presented for evaluation of a congenital nevus on his leg. The physician noted that he had an unusual appearance, including bitemporal scars resembling forceps marks. The mother told us that he had had linear scar-like depressions on both temples since birth. Furthermore, the pregnancy and birth had been normal, and the delivery had not required the use of forceps or other instruments. The parents were healthy and the patient was normal, except for mild strabismus and hypermetropia. Examination revealed bilateral, hyperpigmented, depressed, sharply demarcated atrophic areas on the temples (Fig. 1). The other clinical manifestations were low frontal hairline, dense eyebrows, thick lips, long upper and lower eyelashes and a bulbous nose (Fig. 2). No other cranial or extracranial disorders were observed. Examination of his maternal grandmother revealed that she had similar scar-like lesions on both temples (Fig. 3). Histologic examination of a 3 mm punch biopsy specimen from a lesion on his right temple showed a thinned epidermis and dermis without skin appendages. Little elastic tissue was found in the dermis. Results of routine laboratory studies were within normal limits.

Urine metabolome in women with Chlamydia trachomatis infection

The aim of this study was to characterize the urine metabolome of women with Chlamydia trachomatis (CT) uro-genital infection (n = 21), comparing it with a group of CT-negative subjects (n = 98). By means of a proton-based nuclear magnetic resonance (1H-NMR) spectroscopy, we detected and quantified the urine metabolites of a cohort of 119 pre-menopausal Caucasian women, attending a STI Outpatients Clinic in Italy. In case of a CT positive result, CT molecular genotyping was performed by omp1 gene semi-nested PCR followed by RFLP analysis. We were able to identify several metabolites whose concentrations were significantly higher in the urine samples of CT-positive subjects, including sucrose, mannitol, pyruvate and lactate. In contrast, higher urinary levels of acetone represented the main feature of CT-negative women. These results were not influenced by the age of patients nor by the CT serovars (D, E, F, G, K) responsible of the urethral infections. Since the presence of sugars can increase the stability of chlamydial proteins, higher levels of sucrose and mannitol in the urethral lumen, related to a higher sugar consumption, could have favoured CT infection acquisition or could have been of aid for the bacterial viability. Peculiar dietary habits of the subjects enrolled, in term of type and amount of food consumed, could probably explain these findings. Lactate and pyruvate could result from CT-induced immunopathology, as a product of the inflammatory microenvironment. Further studies are needed to understand the potential role of these metabolites in the pathogenesis of CT infection, as well as their diagnostic/prognostic use.

Erythematous papules on the parasternal region in a 76‐year‐old man

A 76-year-old man presented with a diffuse eruption that had started a few months previously. He had a history of several years of muscle weakness and fatigue associated with mild joint pain and weight loss. He reported itching, abundant salivation and excessive sweating. Over several months, he had developed confusional episodes with disorientation, visual and auditory hallucinations, complex behaviour during sleep and progressive nocturnal insomnia. Before presentation to us, a diagnosis of Morvan’s syndrome had been made at the Neurological Clinical Department, University of Bologna. Physical examination revealed many erythematous papules on the trunk, especially on the parasternal region. (Fig. 1), and the patient reported mild itching and pain. An excisional biopsy was obtained from one of the lesions (Fig. 2).

Sexually transmitted rectal infections in a cohort of ‘men having sex with men’

Purpose. We assessed the prevalence and predictors of Chlamydia trachomatis, Neisseriagonorrhoeae and Mycoplasmagenitalium rectal infections in a population of ‘men having sex with men’ (MSM). Methodology. From January to November 2017, 165 MSM attending a STI outpatients clinic in Bologna (Italy) and reporting unsafe anal intercourses were enrolled. An ano‐rectal swab was collected from each patient: chlamydial and gonococcal infections were diagnosed by a commercial NAAT, whereas an in‐house quantitative PCR was used for M. genitalium detection. In addition, 131 urine samples and 84 pharyngeal swabs underwent testing for C. trachomatis and N. gonorrhoeae. A molecular C. trachomatis typing, a serological screening for anti‐Chlamydia IgG and IgA, as well as the assessment of HIV, HCV and syphilis infections, were performed. Results/Key findings. The prevalence of C. trachomatis, N. gonorrhoeae and M. genitalium rectal infections was 27.2, 25.4 and 4.8 %, respectively. Globally, 63.1 % of cases were asymptomatic and up to 80 % of chlamydial and gonococcal infections would have been missed if the rectal site had not been tested. All the patients with rectal M. genitalium carriage were asymptomatic and characterized by low bacterial loads (<2500 DNA copies/reaction). Lymphogranuloma venereum (LGV) prevalence was 12.1 % with a considerable proportion of asymptomatic infections (35 %). The presence of symptoms, age >30, HIV‐positivity and elevated levels of anti‐Chlamydia antibodies were the most significant predictors of LGV. Conclusions. Sexually transmitted rectal infections are frequent and often asymptomatic among MSM. LGV prevalence is high in our country and there is increasing evidence of symptomless cases.

Insights Into Vaginal Bacterial Communities and Metabolic Profiles of Chlamydia trachomatis Infection: Positioning Between Eubiosis and Dysbiosis

The vaginal microbiota plays a crucial role in maintaining the health and functioning of the female genital tract, preventing the colonization of urogenital pathogens and sexually transmitted infections. In this study, we characterized the vaginal bacterial communities and the metabolome associated to Chlamydia trachomatis infection (CT: 20 women), compared to healthy condition (H: 22 women) and bacterial vaginosis (BV: 19 women). A microarray-based tool (VaginArray), implemented with a real-time PCR for Gardnerella vaginalis, was used to determine the vaginal bacterial composition, whereas the metabolic profiles were assessed by a proton-based nuclear magnetic resonance (1H-NMR) spectroscopy. CT infection was characterized by bacterial and metabolic signatures similar to healthy condition, even though higher amounts of Lactobacillus iners, as well as depletion of some amino acids, biogenic amines, and succinate marked CT infection. Moreover, the frequency of Lactobacillus crispatus was higher in asymptomatic CT-positive patients than in women with CT-correlated symptoms. We also confirmed the marked differences in the microbiome and metabolome between healthy and BV-affected women. In conclusion, we highlighted microbial and metabolic peculiarities of the vaginal ecosystem in the case of CT infection, even though further studies are needed to understand if the observed alterations precede the infection onset or if the pathogen itself perturbs the vaginal environment.

P1.14 Evaluation of the aptima assays for the detection of bacterial sexually transmitted infections in a selected population of women

Introduction: Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG) represent the most common agents of bacterial sexually transmitted infections (STIs), worldwide. In women, uro-genital infections caused by these microorganisms are often asymptomatic and, left untreated, can lead to several sequelae. Nucleic acid amplification techniques (NAATs) have become the reference methods for the diagnosis, thanks to the suitability for different specimens and the outstanding sensitivity and specificity. The aim of this study was to assess the performance of Aptima Assays for CT, NG and MG detection in a group of selected women, by a head-to-head comparison with other NAATs. Moreover, an evaluation about the suitability for the Aptima assays with one of the most used swab collection device (E-Swab; Copan) was carried out. Methods Routinely, all the women attending the STI Outpatients Clinic of Sant’Orsola-Malpighi Hospital of Bologna (Italy) complaining of genital STI-related symptoms or reporting unsafe intercourse, are managed as follows. After a clinical visit, a sample of first-void urines and a vaginal swab collected in E-swab, are obtained for CT, NG and MG detection. A duplex real-time PCR (Versant CT/GC DNA 1.0 assay; Siemens) is used for CT and NG detection, while, MG presence is investigated by a home-made PCR, starting from the remaining eluate of Versant PCR plate. From January 2016, a total of 100 patients were selected and their samples were also tested with Aptima assays. Previously frozen samples were thawed and transferred to the suitable collection devices for Aptima assays: in particular, 2 ml of urines and 100 µl of vaginal E-swab were used. All the specimens were processed by Aptima Combo2® for CT and NG detection and by the Aptima® Mycoplasma genitalium assay for MG infection diagnosis. These assays were run on Panther system (Hologic). A comparison between the different molecular methods, stratified by type of sample and microorganism, was conducted. Results In the group of 100 women selected, 25 patients were positive for CT, 4 for NG and 6 for MG. One case of CT-NG and two cases of CT-MG co-infections were found. Interestingly, more than 50% of CT-positive women were completely asymptomatic. By the routine tests, all positive cases were simultaneously found both on the urine sample and on the vaginal swab, except for 3 CT, 1 NG and 1 MG infections, detected only on the vaginal swab. A complete concordance with Aptima assays, both for the type of sample and microorganism was found, with only one discordant result (a CT case detected by Versant on urines and vaginal swab, found by Aptima only on urines). Any interference due to the different liquid components of E-Swab was excluded. Conclusion Given the outstanding performance, Aptima assays can represent an excellent choice for CT, NG and MG molecular detection. Moreover, it is noteworthy that Aptima assays allow testing of specimens collected by E-Swab, enabling the possibility to use the same sample for both NG molecular detection and culture.

P1.13 Vaginal microbiome signatures in chlamydia trachomatis infected women

Introduction In healthy women, lactobacilli play a crucial role in maintaining the microbial homeostasis of the vaginal niche. In case of bacterial vaginosis (BV), a condition characterised by a depletion of lactobacilli and an increasing number of anaerobes, a higher risk of urogenital and sexually transmitted infections (STIs) is reported. The vaginal environment of healthy and BV-positive women have been extensively studied, leading to the identification of the microbial species dominating these opposite conditions and to the description of specific metabolic profiles. Besides that, less is known about the vaginal microbiome in case of STIs, as Chlamydia trachomatis (CT) infections. The aim of this study was to analyse the composition of the endogenous microbiota and the metabolic signatures of the vaginal niche in 3 different conditions: healthy, BV and CT infections. Methods From July 2016, all the pre-menopausal women attending the STI Outpatients Clinic of Sant’Orsola-Malpighi Hospital in Bologna (Italy) and meeting one of the following criteria were enrolled: presence of vaginal symptoms or presence of risk factors for CT infection. Patients with vaginal candidiasis were excluded. For all the patients, a vaginal swab was collected for molecular CT detection (Versant CT/GC DNA 1.0 Assay; Siemens), whereas Amsel criteria were used for BV assessment. Moreover, for each woman, an additional vaginal swab stored in saline was collected and centrifuged. Cell pellets were examined with a DNA-microarray platform including 17 probe sets specific for the most representative vaginal bacterial groups and with a quantitative real-time PCR targeting 16s rRNA gene of Gardnerella vaginalis (GV). Cell-free supernatants were used for metabolomic analysis by means of 1H-NMR spectroscopy. NMR spectra were recorded with an AVANCE spectrometer (Bruker). Similarities among microbial and metabolic profiles of samples were investigated by means of a principal component analysis (PCA). Differences in GV DNA loads and metabolites concentrations were analysed by ANOVA test. The study was approved by the Hospital Ethical Committee. Results Among all the women enrolled, 25 were considered healthy, 18 received a diagnosis of BV and 22 were positive for CT. PCA revealed that the vaginal microbiome of healthy and BV-subjects were clearly distinct and that CT-positive women were more similar to healthy women rather than to BV-positives, both for microbial composition and for metabolic profile. The mean GV DNA load was significantly different between the groups (p=0.03): healthy and CT positive women showed similar and lower mean loads compared to BV group. At a metabolic level, significantly higher concentrations of formate, ethanolamine and methylamine were found in BV-patients, while tryptophan and lactate were more present in healthy and CT-positive women. Conclusion Specific microbial and metabolic signatures characterise different clinical conditions of the vaginal tract. In this context, CT-positive women are definitely more similar to healthy than BV-subjects.

Congenital nodular lesion of the anterior thorax in a child

A 2-year-old boy was referred to us for an asymptomatic lesion located on the anterior thorax. His parents reported that the lesion, present since birth, had slowly grown, mainly over the past 3 months. On physical examination, the lesion appeared as an oval domeshaped papule, 3 · 4 mm in diameter. The surface of the lesion was smooth and it was pink in colour. It showed no central umbilication, but appeared very similar to a molluscum contagiosum (Fig. 1). On palpation, it was firm and mobile. We decided to excise the lesion, and the biopsy specimen was sent for histopathological examination.