One-year surveillance for hypervirulent Klebsiella pneumoniae detected carbapenem-resistant superbugs.

Hypervirulent Klebsiella pneumoniae (hvKp) can cause infections in clinically healthy people, such as young and immunocompetent patients. Genes involved in the capsule synthesis or those encoding the siderophores have been adopted as predictors of hvKp. Certain sequence types, such as ST23 and ST86, have been associated with hvKp strains, too. The aim of this study was to investigate the presence of hvKp among 354 K. pneumoniae strains isolated from clinical samples of patients admitted to an Italian 900-bed hospital between 21 May 2021 and April 2022. All the isolates were screened by PCR for the amplification of virulence loci. Whole genome sequencing was performed in strains tested positive for at least one target gene. Thirteen out of 354 (3.7%) were hvKp. Five were wild type and belonged to the hypervirulent clones ST23, ST86, ST5, and ST375 and to the new clone ST6310. Six strains carried the blaKPC gene: three belonged to ST101, two to ST512, and one to ST395. Two isolates were ST147 and carried the blaNDM gene. Although hvKp isolation is not frequent, their presence should be systematically investigated to avoid the spreading of both virulent strains and strains with combined increase in virulence and resistance to antibiotics. PCR-based protocols are essential for surveillance of these strains, which do not always show a recognizable phenotype. Moreover, hvKp strains were isolated also from patients without history of recent foreign travels, indicating an increased spreading of these strains as well as an underestimated of their circulation so far.IMPORTANCEKlebsiella pneumoniae is a healthcare-associated pathogen frequently resistant to antibiotics. Hypervirulent strains of pneumoniae (hvKp) can spread from the primary site of infection to multiple sites causing life-threatening infections also in young otherwise healthy individuals. This study described the isolation of 13 isolates of K. pneumoniae with increased virulence in a large tertiary hospital over a 1-year period. Among them, eight strains were multidrug resistant and hypervirulent. Although these hypervirulent strains are still rare in Italy, their presence is particularly concerning since they can cause difficult-to-treat life-threatening infections. Moreover, not all the hypervirulent isolates were positive by the string test, so hvKp isolates were not always phenotypically detectable. Molecular biology techniques such as PCR amplification and next generation sequencing are therefore necessary for the detection of hvKp isolates, and surveillance programs exploiting molecular techniques are highly desirable.

Combining Genome Surveillance and Metadata To Characterize the Diversity of Staphylococcus aureus Circulating in an Italian Hospital over a 9-Year Period.

Staphylococcus aureus is an opportunistic pathogen and a leading cause of morbidity and mortality worldwide. Genomic-based surveillance has greatly improved our ability to track the emergence and spread of high-risk clones, but the full potential of genomic data is only reached when used in conjunction with detailed metadata. Here, we demonstrate the utility of an integrated approach by leveraging a curated collection of clinical and epidemiological metadata of S. aureus in the San Matteo Hospital (Italy) through a semisupervised clustering strategy. We sequenced 226 sepsis S. aureus samples, recovered over a period of 9 years. By using existing antibiotic profiling data, we selected strains that capture the full diversity of the population. Genome analysis revealed 49 sequence types, 16 of which are novel. Comparative genomic analyses of hospital- and community-acquired infection ruled out the existence of genomic features differentiating them, while evolutionary analyses of genes and traits of interest highlighted different dynamics of acquisition and loss between antibiotic resistance and virulence genes. Finally, highly resistant clones belonging to clonal complexes (CC) 8 and 22 were found to be responsible for abundant infections and deaths, while the highly virulent CC30 was responsible for rare but deadly episodes of infections. IMPORTANCE Genome sequencing is an important tool in clinical microbiology, as it allows in-depth characterization of isolates of interest and can propel genome-based surveillance studies. Such studies can benefit from ad hoc methods of sample selection to capture the genomic diversity present in a data set. Here, we present an approach based on clustering of antibiotic resistance profiles that allows optimal sample selection for bacterial genomic surveillance. We apply the method to a 9-year collection of Staphylococcus aureus from a large hospital in northern Italy. Our method allows us to sequence the genomes of a large variety of strains of this important pathogen, which we then leverage to characterize the epidemiology in the hospital and to perform evolutionary analyses on genes and traits of interest. These analyses highlight different dynamics of acquisition and loss between antibiotic resistance and virulence genes.

Livestock-associated methicillin-resistant Staphylococcus aureus in inpatients: a snapshot from an Italian hospital.

OBJECTIVES: This study aimed to characterize livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) strains isolated from patients admitted to Policlinico San Matteo in Pavia, located in an Italian region with high livestock density. METHODS: The starting dataset was composed by 353 MRSA strains isolated from blood cultures between 2011 and 2019 and in 954 MRSA isolated from nasal swabs, wound swabs, skin swabs, ulcer swabs, conjunctival swabs, urine and respiratory samples collected between 2018 and 2019. LA-MRSA was identified based on being MRSA resistant to tetracycline and negative for the PCR amplification of scn locus. Whole genome sequencing of the selected strains was performed, and virulence and resistance genes searched. RESULTS: Five out of 353 MRSA isolates from blood cultures (1.4%) and nine out of 904 MRSA isolates obtained from other materials (1%) were resistant to tetracycline and negative for the scn locus. The 14 strains were also negative for the lukS-pv, tsst, eta and etb loci. Nine of the 14 strains belonged to ST398, the most common ST of LA-MRSA in Europe. ST398 isolates belonged to four spa-types, of which the prevalent was t899. Eight genomes had the cassette SCCmec type V, five genomes had SCCmec type IV and one genome lacked SCCmec, mecA and mecC. CONCLUSION: The frequency of LA-MRSA in the patients of this study (1.4% in blood cultures, 1% in other samples) is low but relatively constant over time prevalence and comparable to that found in the few studies performed on patients to date.

Epidemiology and microbiology of prosthetic joint infections: a nine-year, single-center experience in Pavia, Northern Italy.

BACKGROUND: Prosthetic joint infections (PJIs) are a growing matter of concern due to their economic and social burden on health systems. In Italy, surgical data on PJIs are available in a national registry, but microbiological data are still scarce. MATERIALS AND METHODS: We performed a retrospective study at a single center with records of patients treated for primary PJIs of knee or hip from January 1, 2011, to May 30, 2018. Patients with infections of osteosynthesis means and external devices were excluded, as well as PJI recurrences and polytrauma patients. Infections were diagnosed according to IDSA and MSIS criteria. We collected data on demographics, risk factors and microbiology. All patients seen at our center undergo blood cultures and synovial fluid cultures, periarticular biopsy and prosthesis sonication by Bactosonic®. This was used only after 2014. Bacterial identification is achieved by MALDI-TOF, PHOENIX 100 and standard methods. Chi-square or Fisher tests were used to test statistical differences in proportions. RESULTS: Fifty-one patients matched our inclusion criteria. Of these, 16 (31.4%) were enrolled before 2014. The median age was 68.5 (range 22-88). The most common risk factors were obesity (34%), diabetes (21%) and chronic kidney disease (14%). Seventeen patients were diagnosed with a culture-negative PJIs (33.3%). Staphylococcus aureus was the most commonly isolated pathogen (14/51, 27.5%), followed by coagulase-negative staphylococci (7/51, 13.7%). Methicillin-resistant S. aureus rate was 28.6%. The rate of culture-negative PJIs dropped from 56 to 22% after 2014, with a significant difference between the two time periods (p = 0.016). CONCLUSIONS: The introduction of sonication dramatically increased our diagnostic accuracy. Our microbiological data are in line with those from other studies conducted in Italy.

Prevention of nosocomial legionellosis by best water management: comparison of three decontamination methods.

BACKGROUND: Since 2000, the National Health System has adopted international guidelines for assessing Legionella spp. in hospital water systems. The control of water contamination by Legionella spp. is still a matter of research concerning the most effective method in preventing nosocomial infections. AIM: To compare three different decontamination methods by monitoring colony-forming unit count and number of hospital-acquired legionellosis cases. A secondary objective was to evaluate the long-term effects of the preventive measures on the water pipes. METHODS: A protocol was developed for the selection of high-risk sampling sites and for the testing of three disinfection methods over the course of 19 years: hyperchlorination and thermal shock (period A, 2000-2005); copper-silver ionization (period B, 2006-2010); and integration of pre-filtering, filtering, pipe-protecting products, and remote control with chlorine dioxide (ClO2) (period C, 2011-2018). FINDINGS: The use of shock disinfection and hyperchlorination led to a decrease in contamination level immediately after the procedure, but then it rose again to the previous level in two months. Both copper-silver ionization and ClO2 disinfection showed a stable and durable decrease in contamination level. Throughout these three phases, six cases of Legionella spp. occurred during period A, six cases during period B, and three cases during period C. With regard to the damage of water pipes, effective copper-silver levels caused corrosion and calcification in water pipes. CONCLUSION: Both copper-silver ionization and ClO2 properly controlled Legionella spp. contamination. ClO2 significantly reduced the number of positive sites (P < 0.001) without damaging the pipelines.

Evaluation of a model to improve collection of blood cultures in patients with sepsis in the emergency room.

Sepsis begins outside of the hospital for nearly 80% of patients and the emergency room (ER) represents the first contact with the health care system. This study evaluates a project to improve collection of blood cultures (BCs) in patients with sepsis in the ER consisting of staff education and completion of the appropriate BC pre-analytical phase. A retrospective observational study performed to analyse the data on BC collection in the ER before and after a three-phase project. The first phase (1 January to 30 June 2015) before the intervention consisted of evaluation of data on BCs routinely collected in the ER. The second phase (1 July to 31 December 2015) was the intervention phase in which educational courses on sepsis recognition and on pre-analytical phase procedures (including direct incubation) were provided to ER staff. The third phase (1 January to 30 June 2016; after the intervention) again consisted of evaluation. Before the intervention, out of 24,738 admissions to the ER, 103 patients (0.4%) were identified as septic and had BCs drawn (359 BC bottles); 19 out of 103 patients (18.4%) had positive BCs. After the intervention, out of 24,702 admissions, 313 patients (1.3%) had BCs drawn (1,242 bottles); of these, 96 (30.7%) had positive BCs. Comparing the first and third periods, an increase in the percentage of patients with BCs collected (from 0.4% to 1.3% respectively, p < 0.0001) and an increase in the percentages of patients with true-positive BCs (from 0.08% to 0.39% of all patients evaluated respectively, p < 0.0001) were observed. The isolation of bacteria by BCs increased 3.25-fold after project implementation. These results can be principally ascribed to an improved awareness of sepsis in the staff associated with improved pre-analytical phase procedures in BC collection.

Phytoavailability of antimony and heavy metals in arid regions: the case of the Wadley Sb district (San Luis, Potosí, Mexico).

This paper presents original results on the Sb and heavy metals contents in sediments and waste tailings, plants and water from the giant Wadley antimony mine district (San Luis Potosí State, Mexico). The dominant antimony phases in mining wastes are stibiconite, montroydite and minor hermimorphite. The waste tailings contain high concentrations of metals and metalloids (antimony, iron, zinc, arsenic, copper, and mercury). Manganese, copper, zinc, and antimony contents exceed the quality guidelines values for groundwater, plants and for waste tailings. Results indicate that peak accumulation is seasonal due to the concentration by high metabolism plants as Solanaceae Nicotiana. The metal phytoavailability in waste tailings is highly dependant on the metal speciation, its capability to be transported in water and, more particularly, the plant metabolism efficiency.

Wagner's spherical periacetabular osteotomy: long term results.

Residual acetabular dysplasia leads to hip arthritis as a consequence of insufficient femoral head coverage which causes abnormal pressure on the joint cartilage. Spherical periacetabular osteotomy, described by H. Wagner, improves the acetabular coverage of the head. This surgical technique has been performed by the senior author, in Galeazzi Orthopaedic Institute of Milan, Italy since 1979. The purpose of this study is to evaluate the clinical and radiographic results of 14 patients affected by acetabular dysplasia and operated before 1985 by the same surgeon with this technique. The analysis of long term results (follow-up longer than 20 years) has shown that it is possible to achieve good clinical outcomes and to delay the need for total hip arthroplasty if a precise surgical technique is employed and if the correct indications are followed. Obese patients or hips with X-ray signs of osteoarthritis show the worst results in our experience. Our attitude is nowadays: full indication of spherical periacetabular osteotomy in dysplasia of the adolescent, indication in young adult patients only when some symptom is present, very rare indication in arthritis and only in very mild cases in young patients.

Real-time reverse transcription-PCR analysis of expression of halobenzoate and salicylate catabolism-associated operons in two strains of Pseudomonas aeruginosa.

Pseudomonas aeruginosa JB2 can use 2-chlorobenzoate (2-CBa), 3-CBa, 2,3-dichlorobenzoate (2,3-DCBa), and 2,5-DCBa as sole carbon and energy sources, whereas strain 142 can only grow on 2-CBa and 2,4-DCBa. Both strains, however, harbor the same halobenzoate 1,2-dioxygenase (ohbAB) and chlorocatechol (clcABD) degradation genes necessary for the metabolism of ortho-CBas. In addition, the hybABCD operon, encoding a salicylate 5-hydroxylase, is also found in both strains. The expression of ohbAB, hybABCD, and clcABD operons was measured in cultures grown on different CBas as the sole carbon source and also in glucose-grown cells supplemented with CBas as inducers. A method to standardize real-time reverse transcription-PCR experimental data was used that allows the comparison of semiquantitative mRNA accumulation in different strains and culture conditions. In both strains, the ohb and hyb systems were induced in cells grown on 2-CBa or DCBas, whereas clc was induced only by DCBas. Repression by catabolite was observed both on ohb and clc systems in glucose-grown cells. Chlorocatechol 1,2-dioxygenase activity in JB2 was detected even in clc-repressed conditions, confirming the presence of additional isofunctional genes previously detected in P. aeruginosa 142. Although similar levels of induction of ohbAB were observed in strain JB2 grown on either benzoate, monochlorobenzoates, or DCBas, the ohbAB operon of strain 142 was only strongly induced by growth on 2-CBa and, to a lesser extent, on 2,4-DCBa. This observation suggests that regulation of the ohbAB operon may be different in both strains. The concomitant induction of ohb and hyb by CBas may allow the formation of hybrid halobenzoate dioxygenase(s) composed of Ohb/Hyb dioxygenase subunits and Hyb ferredoxin/ferredoxin reductase components.

Induction of the halobenzoate catabolic pathway and cometabolism of ortho-chlorobenzoates in Pseudomonas aeruginosa 142 grown on glucose-supplemented media.

The aerobic cometabolism of ortho-substituted chlorobenzoates by Pseudomonas aeruginosa strain 142 growing on glucose-supplemented medium was analyzed. The strain, which can use 2-chlorobenzoate (2-CBA) and 2,4-dichlorobenzoate (2,4-DCBA) as sole carbon and energy sources, showed high rates of 2-CBA metabolism in glucose-fed cells. In contrast, 2,4-DCBA was metabolized only after extended incubation of the full grown culture and depletion of glucose. In addition to the ortho-dehalogenation (ohb142) genes encoding the alpha and beta subunits of the oxygenase component of a 2-halobenzoate dioxygenase, strain 142 harbours a closely related ohbABCDFG gene cluster previously identified in P. aeruginosa JB2 (ohbJB2). The genes for the chlorocatechol ortho-catabolic pathway were identified and sequenced in this strain, showing a near complete identity with the clcABD operon of the pAC27 plasmid. Relative quantification of mRNA by RT-PCR shows a preferential induction of ohb142 by 2-CBA, which is abolished in glucose-grown cultures. The alternate ohbJB2 and clc genes were expressed preferentially in 2,4-DCBA grown cultures. Only ohbJB2 appears to be expressed in the presence of the carbohydrate. Detection of chlorocatechol-1,2-dioxygenase activity in 2,4-DCBA plus glucose grown cultures suggests the presence of an alternate system for the ortho-cleavage of chlorobenzoates. The recruitment of elements from two halobenzoate dioxygenase systems with different induction patterns, together with a chlorocatechol degradative pathway not repressed by carbon catabolite, may allow P. aeruginosa 142 to cometabolize haloaromatics in carbohydrate grown cultures.

Tricoblastoma / Trichoblastoma

En 1962 Headimgton describió un tumor benigno y mesenquimático que recapitulaba en forma parcial o completa el desarrollo del folículo piloso, al que denominó tumor anexial tricogénico. En 1976 el mismo autor realizó una revisión de las neoplasias del germen piloso y las clasificó en base al grado de diferenciación y a la relación entre el componente epitelial y el mesenquimático. Recientemente Ackerman y col. propusieron el nombre de tricoblastoma para todas aquellas neoplasias benignas con diferenciación folicular, incluyendo a todos los tumores de la clasificación de Hradigton. Presentamos tres casos de tricoblastoma describiendo sus características clínicas y patológicas remarcando las diferencias entre éste y el carcinoma basocelular

Porfiria cutánea tarda esclerodermiforme: presentación de cuatro casos y revisión de la literatura / Sclerodermic porphyria cutanea tarda: report of 4 casis and a review of the literature

La porfiria cutánea tarda esclerodermiforme (PCTE) es una forma poco frecuente de la presentación de la porfiria cutánea tarda (PCT), representando el 18-33 por ciento de los casos. Se caracteriza por manifestarse con placas esclerodermiformes de aparición insidiosa y tardía en el curso de la enfermedad. El déficit de la actividad de la enzima uroporfirinógeno decarboxilasa (UPDC), lleva a la acumulación de metabolitos intermedios responsables de las manifestaciones clínicas y bioquímicas. Se presentan cuatro pacientes con PCTE estudiados en nuestro Servicio, en un período de cuatro años (1992-1996)

Plasma and erythrocyte alpha-tocopherol and plasma retinol concentrations in term infants fed formula enriched with long-chain polyunsaturated fatty acids.

OBJECTIVE: To assess the effect of long-chain polyunsaturated fatty acids (LCPUFA)- and vitamin E-supplemented formula feeding on erythrocyte and plasma alpha-tocopherol (VE), and plasma retinol (VA) concentrations in neonates and to compare these values with those found in infants feeding on infant formula without LCPUFA or breast milk SETTING: University Hospital of Granada, Spain. SUBJECTS: 49 full-term infants. DESIGN AND INTERVENTION: Subjects who chose not to breast feed were fed either (i) unsupplemented infant formula (F) or (ii) infant formula supplemented with LCPUFA and vitamin E (FL). Alpha-tocopherol and retinol were measured at 7 days, 1 month and 3 months. RESULTS: Plasma and erythrocyte VE concentrations and plasma VE/total lipids ratio increased significantly in all groups at 1 month of life (P < 0.05), but did not change significantly between 1 month and 3 months in any group (P > 0.05). Erythrocyte VE and VA retinol concentrations were higher in infants fed an infant formula than in breast milk-fed infants at 1 month of life (P < 0.05). Finally, there were no significant differences in plasma or erythrocyte VE levels, plasma VA or plasma VE/total lipid ratio between any groups at 3 months of life (P > 0.05). CONCLUSION: Infants fed on LCPUFA- and vitamin E-supplemented infant formula for 3 months have similar vitamin E and A status to infants fed on breast milk or infant formula without LCPUFA supplementation.

Fatty acid composition of plasma and erythrocytes in term infants fed human milk and formulae with and without docosahexaenoic and arachidonic acids from egg yolk lecithin.

Human milk contains small but nutritionally significant amounts of long-chain polyunsaturated fatty acids (LCP), such as arachidonic (AA, 20:4n-6) and docosahexaenoic (DHA, 22:6n-3) acids, which are not present in most infant formulae. In the present study, the fatty acid composition of plasma and erythrocytes was determined at birth and again at 7 days, 1 and 3 months in 49 healthy full-term infants (37-42 week's gestation). One group of infants was fed exclusively with human milk (n=16) and the others were randomly assigned to a standard term formula (F) (n=15) or the same formula with egg yolk lecithin providing DHA (0.15%) and AA (0.30%) (LCP-F) (n=18). Plasma and erythrocyte LCP values of the three dietary groups did not differ at 7 days of age, but the contents of DHA and AA in plasma and erythrocytes at 1 and 3 months were significantly lower (P<0.05) in infants fed non supplemented formula than in infants fed breast milk and supplemented formula. There were no differences in plasma or erythrocyte AA or DHA concentrations between the group fed breast milk and the group fed supplemented formula during the period studied.

Influence of caesarean delivery and maternal factors on fat-soluble vitamins in blood from cord and neonates.

We measured plasma and erythrocyte vitamin E (VE) and plasma vitamin A (VA) profiles in 48 full-term and 8 preterm pairs of neonates and their mothers at birth and we determined whether there is any relationship between maternal and umbilical cord for the nutrients measured. At the same time, we assessed the influence of the delivery type and neonate anthropometric measurements on maternal and cord blood VA and VE levels. We measured vitamin levels in vein and arterial blood in order to establish differences due to fetal metabolism. To determine the influence of pregnancy on vitamin levels, we compared the maternal results with data from a group of 13 non-pregnant women. Cord blood had lower plasma VE (arterial 275.8+/-71.7 microg/dl and vein 282.89+/-64.4 microg/dl values), erythrocyte VE (arterial 256.96+/-50.41 microg/dl packet cells and vein 257.41+/-44.35 microg/dl values), and VA levels (arterial 26.72+/-11.83 microg/dl and 27.15+/-10.05 microg/dl values) and a lower vitamin E/total lipids ratio (VE/LT) (arterial 1.60+/-0.4 and vein 1.62+/-0.3 values) than maternal blood (1474.62+/-424.51 microg/dl, 305.94+/-54.75 microg/dl packet cells, 41.03+/-18.83 microg/dl, 2.34+/-0.5, respectively). VA levels were higher in preterm than full-term neonates (P<0.05). Plasma and erythrocyte VE levels were not correlated in maternal blood but were correlated in neonates and infants (r>0.40; P<0.01). We found a good correlation between erythrocyte tocopherol of maternal and cord blood (r>0.40; P<0.01), although there was no correlation with plasma VE values. Cord vein plasma VE levels were higher than cord arterial blood measurements (P<0.01). The plasma VE and VE/LT of the mother and cord following vaginal delivery were higher than measurements from caesarean delivery (P<0.05), although erythrocyte levels were similar. The plasma VE level was higher in mothers at delivery than non-pregnant women.

[Molecular analysis of glucose-6-dehydrogenase deficiency in Spain]. / Análisis molecular del déficit de glucosa-6-fosfato deshidrogenasa (G6PD) en España.

PURPOSE: G6PD deficiency is the most frequent enzymopathy-producing genetic polymorphism in humans. Up to now, over 400 putative variants of G6PD have been distinguished on the basis of biochemical characterization of the deficient enzyme. Analysis of the G6PD gene has made possible a precise classification of the G6PD molecular variants by identification of about 80 different point mutations causing much of the phenotypic heterogeneity. In the Spanish population, the analysis of G6PD has led to the identification of 15 different point mutations that underlay the phenotypic heterogeneity of G6PD previously reported by biochemical analysis. The purpose of the study has been to identify the genetic mutation responsible of the G6PD deficiency and to improve the knowledge of its genetic homogeneity. PATIENTS AND METHODS: From 50 Spanish males with G6PD deficiency 34 came from out consultation and 16 from the Spanish Study Group on Red Cell Pathology (GEHBTA-Eritropatología) The methods employed included screening of prevalent mutations by ER-PCR, SSCP-PCR, genetic segmentation and biochemical characterization of the deficient enzyme. RESULTS: In 31 cases the mutations were characteristic of the four most frequent polymorphic variants found in Spain (G6PD A-376G/202A, G6PD Mediterranean 563T G6PD Union 1360T and G6PD Seattle 344C). Since these mutations either create or abolish a specific site recognized by a restriction endonuclease (RE), they can be rapidly detected by RE digestion of a PCR-amplified product (PCR-RE). In patients where none of these mutations were present (17 cases), the G6PD gene was subjected to PCR single-strand conformation polymorphism (PCR-SSCP) analysis combined with direct PCR-sequencing. By using this procedure, 9 new mutations have been identified, five of them have been also found in other geographical areas and were associated with favism (G6PD A-376G/968C, G6PD Santamaria 376G/542T, G6PD Aures 143C and G6PD Chatham 1003A) or chronic haemolytic anaemia (G6PD Tomah 1153C). The other four mutations are unique and not reported so far: Three of them are associated with favism (G6PD Málaga 542T, G6PD Murcia 209G and G6PD Valladolid 406T) and one with chronic haemolytic anaemia (G6PD Madrid 1155G). The remaining eight cases are under study. CONCLUSION: The present study confirms the marked genetic heterogeneity of G6PD deficiency in Spain and demonstrate that the PCR-RE analysis is an easy tool for rapid diagnosis of the molecular defect in subjects with the common forms of G6PD deficiency. Furthermore the fact that G6PD A-376G/202A is the most common variant within Spanish population and the finding of G6PD Aures 43C and G6PD Santamaría 76G/542T, who are polymorphic in Algeria is consistent with a significant gene flow from Africa to Europe through Spain.