Factors associated with access to antiviral treatment in a multicentre cross-sectional study of patients with chronic hepatitis B in Italy.

A multicentre cross-sectional survey was performed to provide an accurate picture of patients with chronic hepatitis B (CHB) cared for by Italian Infectious Diseases Centers (IDCs). This analysis describes factors associated with access to the treatment of CHB in a country where barriers to treatment are not expected to exist because of comprehensive coverage under the National Health System (NHS). The study was performed in 74 IDCs. The analysis focused on 3305 patients with CHB of 3760 HBsAg-positive patients enrolled from March to September, 2008. To account for missing values, a Multiple Imputation method was used. Treatment was reported in 2091 (63.3%) patients. In the multivariate analysis, an increased chance of getting treatment was independently associated with 10 years increase of age at diagnosis (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1-1.3, P < 0.001), HBeAg positivity (aOR 1.8, 95% CI 1.1-2.8, P < 0.001), cirrhosis (aOR 3.6, 95% CI 2-6.3, P = 0.012), HDV (aOR 1.6, 95% CI 1.02-2.5, P = 0.042) and HIV positivity (aOR 6.5, 95% CI 4-10.8, P < 0.001). Conversely, a decreased chance was associated with female gender (aOR 0.6, 95% CI 0.5-0.7, P < 0.001), immigration (aOR 0.6, 95% CI 0.5-0.9, P = 0.009), alcohol consumption (aOR 0.7, 95% CI 0.5-0.98, P = 0.04) and HCV positivity (aOR 0.5, 95% CI 0.3-0.8, P = 0.005). Our study shows that Italian IDCs treat a high percentage of patients with CHB. Nevertheless, disparities exist which are not related to the severity of disease limiting access to antiviral therapy of CHB, even in a country with a universal healthcare system.

Molecular identification of Cryptosporidium parvum from avian hosts.

Cryptosporidium species are protozoan parasites that infect humans and a wide variety of animals. This study was aimed at identifying Cryptosporidium species and genotypes isolated from avian hosts. A total of 90 samples from 37 different species of birds were collected throughout a 3-month period from April 2008 to June 2008 in the National Zoo of Kuala Lumpur, Malaysia. Prior to molecular characterization, all samples were screened for Cryptosporidium using a modified Ziehl-Neelsen staining technique. Subsequently samples were analysed with nested-PCR targeting the partial SSU rRNA gene. Amplicons were sequenced in both directions and used for phylogenetic analysis using Neighbour-Joining and Maximum Parsimony methods. Although 9 (10%) samples were positive for Cryptosporidium via microscopy, 8 (8.9%) produced amplicons using nested PCR. Phylogenetic trees identified all the isolates as Cryptosporidium parvum. Although C. parvum has not been reported to cause infection in birds, and the role of birds in this study was postulated mainly as mechanical transporters, these present findings highlight the significant public health risk posed by birds that harbour the zoonotic species of Cryptosporidium.

Kytococcus sedentarius and Micrococcus luteus: highly prevalent in indoor air and potentially deadly to the immunocompromised - should standards be set?

The multifarious types of infections contracted from indoor environments show that buildings can serve as a reservoir for infectious bacteria. This study is an investigation into the type and concentrations of bacteria in the indoor and outdoor environments of an electronic factory, an office and a winery in Malaysia. Trypticase soy agar (TSA) (with ambient air incubation) and TSA supplemented with haemin and NADH (with CO2 enhanced incubation) were used for the isolation of bacteria. The plates were incubated at 37ºC for 3 days. A random selection of bacterial isolates were Gram stained and identified using the BD BBL Crystal Identification Systems. Kytococcus sedentarius and Micrococcus luteus were the predominant bacterial species identified from indoor air. These bacteria were present at relatively high concentrations in indoor air, at times, above 800 colony forming units per cubic meter (CFU/m3) of air. This indicates that both K. sedentarius and M. luteus can survive a wide range of adverse conditions, including chemical contamination and ultraviolet exposure. M. luteus is a known cause of pneumonia in immunocompromised individuals and has also been implicated in skin infections. Recent reports suggest species of kytococci as emerging opportunistic pathogens of the immunocompromised, paediatrics and the elderly. We postulate that opportunistic bacteria, such as the kytococci and the micrococci, may also have a potential role in instigating subclinical, more subtle symptoms of disease in inmmunocompetent individuals.

Field evaluation of a rapid diagnostic test to detect antibodies in human toxocariasis.

Human toxocariasis which is caused mainly by the larvae of Toxocara canis and Toxocara cati, is a worldwide zoonotic disease that can be a potentially serious human infection. The enzyme-linked immunosorbent assay (ELISA) using T. canis excretory-secretory (TES) antigens harvested from T. canis larvae is currently the serological test for confirming toxocariasis. An alternative to producing large amounts of Toxocara TES and improved diagnosis for toxocariasis is through the development of highly specific recombinant antigens such as the T. canis second stage larva excretory-secretory 30 kDa protein (recTES-30). The aim of this study was to evaluate the sensitivity and specificity of a rapid diagnostic kit (RDT, named as iToxocara kit) in comparison to recTES-30 ELISA in Serendah Orang Asli village in Selangor, Malaysia. A total of 133 subjects were included in the study. The overall prevalence rates by ELISA and RDT were 29.3% and 33.1%, respectively, with more positive cases detected in males than females. However, no association was found between toxocariasis and gender or age. The percentage sensitivity, specificity, positive predictive value and negative predictive value of RDT were 85.7%, 90.1%, 80% and 93.2%, respectively. The prevalence for toxocariasis in this population using both ELISA and RDT was 27.1% (36/133) and the K-concordance test suggested good agreement of the two tests with a Cohen's kappa of 0.722, P<0.01. In addition, the followed-up Spearman rank correlation showed a moderately high correlation at R=0.704 and P<0.01. In conclusion, the RDT kit was faster and easier to use than an ELISA and is useful for the laboratory diagnosis of hospitalized cases of toxocariasis.

Treatment of subperiodic Brugia malayi infection with a single dose of ivermectin.

A clinical trial on the efficacy of a single oral dose of ivermectin at 20, 50, 100, and 200 micrograms/kg was carried out in 40 subjects with subperiodic Brugia malayi microfilaremia. There was no significant difference in the clearance of microfilaremia in the four treatment groups, and the lowest geometric mean microfilarial count (GMC) achieved in the 40 subjects was 8.8/ml or 8.3% of the initial count (106.1/ml), at two weeks post-treatment. The GMC started to increase at one month post-treatment and by six months was 22.2% of the initial GMC. Only 27.5%, 23.1%, 15.0%, and 18.9% of subjects were amicrofilaremic at two, four, 12, and 24 weeks post-treatment, respectively. Mild fever in 35% of the subjects was the primary side reaction and was more common in those with microfilarial counts > or = 500/ml (85.7%) than in those with counts < 500/ml (32%). The clearance of B. malayi microfilaremia by ivermectin was less rapid than that reported for Wuchereria bancrofti. The smaller number of side reactions encountered in the present study compared with those reported for bancroftian filariasis is probably related to the lower microfilarial density in the present subjects. Since ivermectin at a single oral dose of 20-200 micrograms/kg can reduce the GMC to less than 10% at two weeks and maintain it below 25% of the initial level even at six months post-treatment, it is recommended that the drug be seriously evaluated for use in the control of brugian filariasis.

Studies on the experimental chemotherapy of Angiostrongylus malaysiensis infection in rats with mebendazole and levamisole.

The effect of levamisole hydrochloride and mebendazole on Angiostrongylus malaysiensis infection in albino rats was studied. Animals at different stages of infection were treated with various oral doses of levamisole and mebendazole with the aim of finding an effective treatment regime. Levamisole was most effective for treating rats seven days after infection but its efficacy dropped as infection progressed. Mebendazole given at a dose of 1 mg/kg for five days was more effective against early larval stages (97.39% efficacy). At 5 mg/kg for five days mebendazole was more effective than levamisole against all stages of the infection.

Serum HBV DNA and intrahepatic hepatitis B core antigen (HBcAg) in chronic hepatitis B virus infection: correlation with infectivity and liver histology.

In this study we investigated the HBeAg/anti HBeAg status, the liver histological features, the intrahepatic localization of HBcAg, and the presence of serum HBV DNA in a group of 79 HBsAg-positive patients. We found a close relationship between the presence of HBV DNA and intrahepatic HBcAg in HBeAg-positive patients. Among the 56 anti-HBeAg-positive patients considered, 13 (23.2%) showed the presence of intrahepatic HBcAg and serum HBV DNA. In this group of patients, active viral replication was associated with a chronic inflammatory liver disease and particularly with CAH. Furthermore, a prevalent cytoplasmic localization of HBcAg was found in 66.6% of patients affected by CAH, showing that this peculiar distribution of HBcAg seems to be associated with a poor prognosis.

Chemotherapy and chemoprophylaxis of Angiostrongylus malaysiensis infection in rats with levamisole and mebendazole.

The chemoprophylactic and chemotherapeutic effects of levamisole and mebendazole on Angiostrongylus malaysiensis infection in rats were studied. Both drugs were ineffective in preventing infection while the post-infection treatment showed 100% efficacy. Furthermore, levamisole and mebendazole when given in combination appeared to have an antagonistic effect.

Seasonal prevalence of the helminth fauna of the wood rat Rattus tiomanicus (Miller) in West Malaysia.

A helminthological examination of 367 wood rats, Rattus tiomanicus, in an oil-palm. estate 24 miles north of Kuala Lumpur conducted during 1973 revealed 8 species of helminths: 5 nematodes. Angiostrongylus malaysiensis (54.2% of the rats infected), Hepatojarakus malayae (48.5%), Nippostrongylus braziliensis (48.0%), Gongylonema neoplasticum (0.3%), Syphacia muris (17.7%); 3 cestodes, Hymenolepis diminuta (6.0%), Hymenolepis nana (7.6%), Hydatigera taeniaeformis (cysticercus) (12.0%) and 1 pentastomid, Armillifer sp. (nymph) (0.8%). Overall helminthic infection rates seemed to be higher than those previously reported in this host species.

Humoral immune response of Balb/c mice to larval and adult worm antigens of Angiostrongylus malaysiensis.

The development of Angiostrongylus malaysiensis in Balb/c mice and the humoral response due to it were studied by using the enzyme-linked immunosorbent assay (ELISA) with adult worm and L3 antigens. The worms recovered from mice were seen in the brain tissue only, they failed to migrate to the lung as in the normal host (rats). The antibody titres of sera from infected mice, showed similar patterns in response to L3 antigen and to adult worm antigen. However, the highest antibody response could be detected by L3 antigen in the early period after infection while the adult worm antigen detected a higher response in the later stages of development.

Humoral and cell mediated immune responses against Schistosoma spindale in BALB/c mice.

(BALB/c mice were infected with cercariae of Schistosoma spindale by tail immersion technique and by dropping some cercariae from a pipet onto the outer surface of the pinna of the ears. Groups of mice were removed on Days 10, 20 and 30 and tested for humoral and cell mediated immune responses using either adult worm or cercarial antigen. On Day 50 the mice were sacrificed and the worm burden was determined for each mouse. This method resulted in an infectivity rate of 89.7%. There was a significant increase in antibody titer to the adult worm antigen while no significant increase was observed for cercarial antigen over the period of the study. Results obtained for cell mediated immunity were more dramatic. There was a significant increase in foot pad swelling for adult worm antigen compared to a significant decrease for cercarial antigen during the course of the infection.

Spargana infection of frogs in Malaysia.

Frogs caught from two States (Selangor and Langkawi) in Malaysia were examined for spargana of Spirometra sp. Infected frogs usually show no marks of infection but some had swelling and bleeding at the infection site. The size and weight of the infected frogs did not correlate with the infection status. The infection status in relation to human health is discussed.

Detection of Angiostrongylus malaysiensis circulating antigen using monoclonal antibody-based enzyme-linked immunosorbent assay (MAb-ELISA).

Three MAbs 1C4.2D8, 1C4.2C4 and 1C4.1F5 were produced using sonicated adult worm antigens of Angiostrongylus malaysiensis and they were found to be secreters of IgG1. The MAbs 1C4.2C4 and 1C4.2D8 were found to react with antigens of A. malaysiensis and cross-react with the closely related A. cantonensis but not with other helminths. A total of 108 human sera collected from Orang Asli (aborigenes) from Grik, in the State of Perak were tested for A. malaysiensis infection using the MAb-ELISA. MAb 1C4.1F5 and 25 (23%) were positive. Twenty of these positive samples were tested with the MAb 1C4.2D8 and none was found to be positive.

Studies on animal schistosomes in Peninsular Malaysia: record of naturally infected animals and additional hosts of Schistosoma spindale.

Surveillance studies on cercarial dermatitis were carried out in paddy growing areas in Peninsular Malaysia. It was observed that dermatitis in paddy planters occurred in paddy fields which were cultivated using animals such as bafflos or fields where domestic animals were allowed to graze during the off planting season as these animals harbored the parasite. The causative agent of cercarial dermatitis was Schistosoma spindale. A total of 215 small mammals trapped from Alor Setar and 126 trapped from Labu were examined for the schistosome. In Alor Setar Bandicota indica, Rattus argentiventer and Rattus rattus diardii were the only wild mammals found to be infected with the parasite, while in the Labu areas only Rattus tiomanicus jalorensis was positive for the schistosome. The occurrence of S. spindale in R. argentiventer and R.r. diardii in Alor Setar and in R.t. jalorensis in Labu constitute new host and geographic distribution records of the schistosome.

Epidemiology and control of malaria in Malaysia.

In spite of more than 30 years of control activities, malaria continues to be the most important parasitic infection in Malaysia, accounting for 39,189 confirmed cases in 1991, giving an annual parasite incidence rate of 2.2 per 1,000 population. Some factors contributing to the continued transmission of malaria are the development of drug resistant Plasmodium falciparum, changes in vector behavior, and ecological changes due to socio-economic reasons. Malaria parasite rates are higher among the Aborigines, land scheme settlers and those in intimate contact with the jungle, like loggers. There has been no substantial change in the proportion of the three common malaria species responsible for infections, P. falciparum, P. vivax, P. malariae and mixed infections accounting for about 70%, 28%, 1% and 1%, respectively of all infections. Drug resistant P. falciparum is unevenly distributed in Malaysia, but based on clinical experience and in vitro drug sensitivity studies, chloroquine resistance is frequently encountered. There has been clinical and laboratory evidence of resistance to sulfadoxine/pyrimethamine combination as well as quinine, but all these have so far been successfully treated with a combination of quinine and tetracycline. The eradication of the disease is impossible in the near future but there is confidence that with better surveillance techniques and the use of alternative control measures like permethrin impregnated bed-nets to complement existing ones, the target of bringing down the annual parasite incidence to 2 per 1,000 population during the Sixth Malaysian Plan period (1991-1995) can be achieved.

The life-cycle of Spirometra species from Peninsular Malaysia.

The life-cycle of Malaysian Spirometra spp. was studied under experimental conditions in the laboratory. The Cyclops were reared as the first intermediate host, the hamster as the experimental second intermediate host and cat as the definitive host. Maturation and hatching of eggs took 6 to 12 days by incubation at temperature 30 ºC. The hatched coracidium measured 46 x 34 µm. The Cyclops used were susceptible to the coracidial infection. The procercoid older than 5 days in the Cyclop body cavity had minute spines at the anterior end, calcium corpuscles in the body parenchyma and the cercomer at the posterior end. Procercoids 10 to 14 days old were infective to hamster. The plerocercoids from the hamster after 30 days were long and slender and were infective to cats. The plerocercoids experimentally inoculated to cats developed to adult worms and began to produce eggs between 10 to 60 days. Based on the results that have been obtained, a complete life-cycle was successfully elucidated in the laboratory and hamster was identified to be a good laboratory model for a second intermediate host of Spirometra sp.

Case report: HIV infection from a kidney transplant.

The transmission of human immunodeficiency virus (HIV) through transplantation of human tissues and organs is rare but not impossible. A 27-year-old Bulgarian woman received a kidney transplant from a cadaveric donor owing to chronic renal failure due to glomerulonephritis of unknown etiology. Five days after the donation, the tissues showed HIV-1 infection, so she was immediately initiated on highly active antiretroviral therapy (HAART) with lopinavir/ritonavir, zidovudine, enfuvirtide, and lamivudine. Subsequently, according to the genotypic test which revealed a complex resistance pattern of the HIV-1, we changed the regimen to darunavir/ritonavir, etravirine, lamivudine, and enfuvirtide. The HIV-1 genome (550 UI/mL), which was detected at 5 days after transplantation, rapidly declined to undetectable levels at 3 weeks after HAART. The CD4+ T-cell nadir was 432 cells/microL (40%) to 1,400 cells/microL after 2 years. The posttransplantation course was complicated by cytomegalovirus pneumonia. At 32 months after transplantation, the patient had experienced hypertension with secondary retinopathy, bilateral cataracts, diabetes, hypothyroidism, osteoporosis with multiple vertebral fractures, a hip prosthesis, and a bone infarction of the femur. Major management problems had been related to steroid and HAART treatment side effects. Therapeutic interactions between the immunosuppressants and the antiretroviral drugs were complex for management, requiring frequent checks of drug levels and dose-adjustments. We finally obtained a stable clinical and viroimmunologic condition. The transmission of multiresistant strains of HIV from unknown patients requires complex multidisciplinary management.

Case report: cystic fibrosis, lung transplantation, and the novel H1N1 flu.

The H1N1 pandemic flu is a significant risk factor for both patients with chronic disease who need organ transplantation and transplant recipients. This population needs special care regarding comorbidities and related complications. MB, a 38-year-old Italian cystic fibrosis male patient with lung and pancreatic involvement, was referred to our division in July 2009 for fever-associated arthromyalgia, headache, and rhinitis. Lung transplantation had been performed in September 2005, and he was subsequently treated with immunosuppressive therapy: tacrolimus, everolimus, and prednisolone. In the past, chronic respiratory colonization with Pseudomonas aeruginosa and intermittent infection with Aspergillus flavus, chronic renal failure, hypertension, and diabetes mellitus complicated his clinical history. He started antiviral treatment with oseltamivir despite no travel history and no respiratory symptoms. H1N1 swab was positive. Three days later, the patient was admitted to the hospital for the persistence of fever and the onset of cough. Chest x-ray showed a left lower pneumonia, which was confirmed by computerized tomography. Broad-spectrum antibiotic therapy led to an improvement of the clinical condition. The patient was discharged 8 days later; a control swab was negative. This case report suggests some general considerations regarding solid organ recipients: 1) Flu-related complications require early treatment (both antiviral and antibiotic); 2) active microbiologic surveillance is important to prevent lethal infections (ie, invasive aspergillosis); 3) evaluation of immunosuppressant blood levels is necessary for drug-drug interactions. Active prevention is the best option for decreasing morbidity and mortality in the transplanted patient.