Unusual clinical manifestation and challenging serological interpretation of syphilis: insights from a case report.

BACKGROUND: The clinical manifestations of recent syphilis can be variable, with typical and atypical patterns. Several conditions may cause atypical clinical aspects, including human immunodeficiency virus (HIV) co-infection. Besides the clinical features, co-infections may completely alter syphilis serological tests, causing interpretative difficulties and diagnostic delays. Aim of the work is to describe the difficulties encountered during the diagnostic evaluation of atypical skin manifestations and of the serology for syphilis of an HIV-infected patient who had contracted it several times. CASE PRESENTATION: In 2020, a 52-year old HIV-positive bisexual male patient was admitted to our department with a 4-month history of moderately itchy cutaneous lesions localized at his neck, trunk and arms. In 2013, the patient presented with a classic syphilitic roseola of the trunk and a secondary syphilis was diagnosed, with increased levels of rapid plasma reagin (RPR), Treponema pallidum hemagglutination assay (TPHA), anti-Treponema pallidum IgM and IgG Index. A second episode occurred in 2018, as a primary syphilis with multiple ulcerative lesions of the penis, and increased levels of RPR, IgG and IgM. In 2019, a further episode of secondary syphilis was treated with Doxycycline. In 2020, erythematous and papular lesions with vesicular components and urticarial erythema multiforme (EM)-like lesions were present at the neck, trunk and arms. Serological tests and Nucleic Acid Amplification Test (NAAT) for Treponema Pallidum were performed, as well as a cutaneous biopsy with histological and immunohistochemical evaluation of one lesion. NAAT was negative for T. pallidum. Serological test results were discordant with a new syphilis infection, showing only increased levels of RPR and anti-Treponema IgG. The cutaneous biopsy revealed a non specific histological pattern, while the immunohistochemical evaluation with anti-spirochetal antibodies was mandatory for the diagnosis of recent syphilis, showing clusters of rod-shaped elements, some of which with spiral form, focally present at the epidermis and adnexal structures. CONCLUSIONS: Nowadays, syphilis may present with atypical clinical and serological features. Physicians should be aware of these possible alterations and consider syphilis even in case of uncommon clinical aspect and unclear serological tests. Cutaneous biopsy and immunohistochemical exam may be mandatory for the diagnosis.

Dupilumab therapy of atopic dermatitis of the elderly: a multicentre, real-life study.

BACKGROUND: Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Furthermore, efficacy and safety of innovative drugs such as dupilumab are not yet well known. OBJECTIVES: A multicentre retrospective, observational, real-life study on the efficacy and safety of dupilumab was conducted in a group of patients aged ≥65 years and affected by severe AD. Their main clinical features were also examined. METHODS: Data of elderly patients with severe (EASI ≥24) AD treated with dupilumab at label dosage for 16 weeks were retrospectively collected. Treatment outcome was assessed by comparing objective (EASI) and subjective (P-NRS, S-NRS and DLQI) scores at baseline and after 16 weeks of treatment. RESULTS: Two hundred and seventy-six patients were enrolled in the study. They represented 11.37% of all patients with severe AD. Flexural eczema was the most frequent clinical phenotype, followed by prurigo nodularis. The coexistence of more than one phenotype was found in 63/276 (22.82%) subjects. Data on the 16-week treatment with dupilumab were available for 253 (91.67%) patients. Efficacy of dupilumab was demonstrated by a significant reduction of all the scores. No statistically significant difference regarding efficacy was found in elderly patients when compared to the group of our AD patients aged 18-64 years, treated with dupilumab over the same period. Furthermore, only 18 (6.52%) patients discontinued the drug due to inefficacy. Sixty-one (22.51%) patients reported adverse events, conjunctivitis and flushing being the most frequent. One (0.36%) patient only discontinued dupilumab due to an adverse event. CONCLUSIONS: Therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile. Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly.

Nickel dermatitis from earrings 15 years after EU directive implementation: a clinical-epidemiological study and a market survey in Rome, Italy.

BACKGROUND: Nickel (Ni) dermatitis remains a highly prevalent allergic condition in Italy. There is a continuous need for clinical and epidemiological surveillance to evaluate whether or not European Ni Directive has been effective in contact allergy prevention. OBJECTIVES: To assess the prevalence of Ni dermatitis among patch-tested patients and self-interviewed school students and to analyse Ni release from earlobe jewellery. METHODS: Results of patch tests performed in 2006-2007, 2015-2016 and 2017-2018 were retrieved. A questionnaire was compiled by 315 secondary school students. Ni release from earring parts was analysed with the EN1811:2015 method. RESULTS: A significant time trend of decreasing Ni positivity from 2006-2007 to 2017-2018 was observed both in the overall population (44.1% in 2006-2007, 33.0% in 2015-2016, 31.6% in 2017-2018, P < 0.0001) and in female patients (P < 0.0001). Conversely, change was not significant in males (P = 0.16). Decrease was significant for all age groups, except for those aged >60 years (P = 0.51). Among 242 students who reported earring use, 130 (54%) reported symptoms at earlobes, mostly associated with jewellery of materials other than gold and silver (59% of those with earlobe symptoms). Ni release exceeded the migration limit in 4/21 (20%) earring parts. CONCLUSIONS: A high prevalence of Ni dermatitis and earlobe symptoms were found in Rome. A decreasing time trend was noted, with a significant decline in Ni sensitivity compared to the situation observed right after Ni Directive implementation. This most likely represents the consequence of reduced Ni content in earring parts, although a major care in the use of Ni-containing objects could contribute to explain these findings.

Predictors of response to omalizumab and relapse in chronic spontaneous urticaria: a study of 470 patients.

BACKGROUND: Chronic spontaneous urticaria (CSU) is defined as spontaneous occurrence of wheals and/or angioedema for ≥6 weeks. Omalizumab is a monoclonal anti-IgE antibody effective in refractory CSU, but its mechanism of action and markers predictive of response remain not completely defined. OBJECTIVES: To correlate baseline levels of two proposed biomarkers, total IgE (bIgE) and d-dimer (bd-dimer), and clinical parameters to omalizumab response and to relapses after drug withdrawal. METHODS: In this retrospective Italian multicentre study, clinical data were collected in 470 CSU patients, and bIgE and bd-dimer were measured in 340 and 342 patients, respectively. Disease activity was determined by Urticaria Activity Score 7 (UAS7) at week 1 and 12 after omalizumab starting. Relapses were evaluated during a 2- and 3-month interval after a first and a second course of treatment, respectively. RESULTS: bIgE correlated to a good response to omalizumab since levels were significantly higher in responders than non-responders (P = 0.0002). Conversely, bd-dimer did not correlate to response. There was no correlation between both bIgE and d-dimer and either first or second relapse. Disease duration was significantly longer in patients who experienced either first or second relapse (P < 0.0001 and P = 0.0105, respectively), while baseline UAS7 correlated only to first relapse (P = 0.0023). CONCLUSIONS: Our study confirms bIgE as a reliable biomarker predicting response to omalizumab in CSU, while it does not support the usefulness of bd-dimer unlike previous findings. CSU duration before omalizumab and baseline UAS7 may be clinical markers of relapse risk.

Dynamics and phylogenetic relationships of HIV-1 transmitted drug resistance according to subtype in Italy over the years 2000-14.

Background: Transmitted drug-resistance (TDR) remains a critical aspect for the management of HIV-1-infected individuals. Thus, studying the dynamics of TDR is crucial to optimize HIV care. Methods: In total, 4323 HIV-1 protease/reverse-transcriptase sequences from drug-naive individuals diagnosed in north and central Italy between 2000 and 2014 were analysed. TDR was evaluated over time. Maximum-likelihood and Bayesian phylogenetic trees with bootstrap and Bayesian-probability supports defined transmission clusters. Results: Most individuals were males (80.2%) and Italian (72.1%), with a median (IQR) age of 37 (30-45) years. MSM accounted for 42.2% of cases, followed by heterosexuals (36.4%). Non-B subtype infections accounted for 30.8% of the overall population and increased over time (<2005-14: 19.5%-38.5%, P < 0.0001), particularly among Italians (<2005-14: 6.5%-28.8%, P < 0.0001). TDR prevalence was 8.8% and increased over time in non-B subtypes (<2005-14: 2%-7.1%, P = 0.018). Overall, 467 transmission clusters (involving 1207 individuals; 27.9%) were identified. The prevalence of individuals grouping in transmission clusters increased over time in both B (<2005-14: 12.9%-33.5%, P = 0.001) and non-B subtypes (<2005-14: 18.4%-41.9%, P = 0.006). TDR transmission clusters were 13.3% within the overall cluster observed and dramatically increased in recent years (<2005-14: 14.3%-35.5%, P = 0.005). This recent increase was mainly due to non-B subtype-infected individuals, who were also more frequently involved in large transmission clusters than those infected with a B subtype [median number of individuals in transmission clusters: 7 (IQR 6-19) versus 4 (3-4), P = 0.047]. Conclusions: The epidemiology of HIV transmission changed greatly over time; the increasing number of transmission clusters (sometimes with drug resistance) shows that detection and proper treatment of the multi-transmitters is a major target for controlling HIV spread.

Italy and Argentina compared: an epidemiological study of occupational diseases.

BACKGROUND: The research presented in this paper analyses the clinic-pathological manifestations and work-related health risks identified among outpatients treated in the hospitals of Rome and Buenos Aires. MATERIALS AND METHODS: The occupational anamnestic data were collected between 2013 and 2014 through questionnaires with specific items aimed at detecting occupational diseases classified by target organ systems in outpatient clinics of cardiology, dermatology, physical medicine, ophthalmology, orthopedics, endocrinology (thyroid and gonads). An inferential statistical analysis was then carried out to evaluate the relationship between nationality, exposure to occupational risks and the prevalence and incidence of the selected pathologies. An univariate statistical analysis was performed for this purpose and, in the case of statistically significant results, a subsequent multivariate analysis was used to evaluate the incidence of occupational risk factors and nationality on the pathology diagnosed in conjunction with other confounding factors such as smoking habits and gender. The total sample consisted of 1090 subjects of both sexes. Risks were grouped into seven categories and diseases into 12 diagnostic groups. We analyzed the correlation between risks and diseases with respect to hospital outpatients and to the total sample then comparing Argentina and Italy's data. RESULTS: Analysis of data revealed a higher prevalence of hypertension and dysmetabolic disorders for DSE (Display Screen Equipment) workers both in Italy and Argentina; however, multivariate analysis showed that smoking represents a confounding factor for this association. A higher prevalence of allergic contact dermatitis (ACD) was found in the population samples of Rome and there appeared to be a correlation between eye disorders/defects and Argentine data source. CONCLUSIONS: Our study suggests the usefulness of collecting occupational anamnestic data from outpatient departments to highlight possible associations between occupational risks, lifestyles and pathologies, so as to implement the appropriate prevention strategies.

Clinical epidemiology of hand eczema in patients accessing dermatological reference centres: results from Italy.

BACKGROUND: Data on the epidemiological impact and clinical characteristics of chronic hand eczema in Southern Europe are lacking. OBJECTIVES: To estimate the prevalence of chronic hand eczema in its different stages of severity and refractoriness to standard therapy in patients accessing Italian dermatological reference centres, and to evaluate sociodemographic and clinical factors associated with each stage. METHODS: A cross-sectional multicentre study was conducted. Adult patients with hand eczema, consecutively accessing 14 centres over a 6-month period, were enrolled. Patients were classified according to disease duration, severity and response to standard therapy with potent topical corticosteroids. Logistical regression was performed to investigate the relationship between sociodemographic and clinical data with different stages of eczema. RESULTS: The total number of participants was 981. Hand eczema was chronic in 83·5% of patients; 21·3% had severe eczema, with 62·0% of these patients refractory to standard therapy. Food processing and related work, the health professions, craft and related trade works (building, plumbing, electrical), hairdressing/beauty and handicraft work were most frequently associated with chronic hand eczema. Severe chronic hand eczema was more likely to be seen in men, older patients and those with less education. Severe and refractory hand eczema was also more likely among the unemployed and patients with allergic rhinitis and/or atopic dermatitis. CONCLUSIONS: Chronic hand eczema is frequent among patients with hand eczema accessing dermatology centres. Many patients were severe and refractory to standard therapy. The appropriate identification of hand eczema is the first step in implementing effective and efficient treatments.

Efficacy of an emollient dermoprotective cream in the treatment of elderly skin affected by xerosis.

AIM: Xerosis cutis is a frequent condition in the elderly and the topical treatments are aimed to maintain a balance between the physiological components of the epidermis and an optimal moisturization. The aim was to evaluate the efficacy of a dermoprotective cream, glycerol and paraffin-based, in the treatment of individuals affected by senile xerosis. METHODS: The patients were recruited at the Professional Dermatology and Allergology Outpatient Clinic of the San Gallicano Dermatological Institute of Rome, between 1st January 2013 and 30th September 2014. To assess the efficacy of the cream, two different areas of treatment were identified in each patient upper the limbs. All patients were staged at baseline (T0) and evaluated after 14 days (T1) and 28 days (T2) of topical treatment, using five clinical parameters: scaling, sensation of skin tightness, presence of fissuring and excoriations from scratching and erythema. The itching degree was also evaluated using a 10-steps analogical scale. RESULTS: Fifty patients with xerosis, 25 with a severe and 25 with a moderate form, over 60 were recruited and evaluated. Median age was 65 years (IQR=61-70). After 28 day of topical administration of the cream, the 54.0% of patients showed the absence of signs of xerosis, the 44.0% a mild form and the 2.0% (one patient) a moderate form. Consistently, a progressive and significative reduction of itching and transepidermal water loss (TEWL), and an improvement in skin hydration was also measured. A good profile of tolerability and no episodes of undesirable side effects, was also observed. CONCLUSION: The topical daily use of a cream glycerol and paraffin-based, seem to able to control the xerosis in elderly patients, with a significant reduction of all associated signs and symptoms. Further additional data should be collected to better confirm the role of the topical treatment in the control of disease.

Management of chronic spontaneous urticaria: practical parameters.

Chronic urticaria (CU) is a skin disorder characterized by transient, pruritic wheals persisting for longer than 6 weeks. According to the European Academy of Allergy and Clinical Immunology (EAACI) guidelines, CU can be categorized into two main types: chronic spontaneous urticaria (CSU), in which the wheals appear spontaneously, and inducible urticaria, that is triggered by physical agents. CSU may be due to triggering factors such as food allergens or infections, but in at least 40% of cases it is autoimmune in origin, caused by circulating autoantibodies anti-FcεR1 or anti-IgE, or autoreactive. In the present paper, re-evaluating the EAACI guidelines, we have developed a document containing some practical indications which are useful for diagnosis and management of CSU in the context of the Italian situation. Concerning CSU treatment, second generation antihistamines are the first-line treatment; these drugs can be used, as second-line treatment, at a higher than licensed dose in patients who do not respond adequately at licensed doses. The third-line treatment includes leukotriene receptor antagonists which, however, do not have a specific indication for the treatment of CSU, cyclosporine, whose use in this disease is still off-label, and omalizumab. The latter is a recombinant monoclonal IgG antibody that binds free IgE, down regulates mast cell function and induces eosinophil apoptosis. Recently, it has emerged as an effective and safe treatment for antihistamine-unresponsive CSU of both autoimmune/autoreactive and non-autoimmune/non-autoreactive, and has been officially approved for use against this disease.

Use of potentially harmful skin-lightening products among immigrant women in Rome, Italy: a pilot study.

BACKGROUND: Skin-lightening products are increasingly common in European cities. These products may contain substances that are banned under EU regulations as they can induce adverse effects, including cutaneous and systemic reactions (e.g., mercury, hydroquinone and topical corticosteroids). OBJECTIVES: To assess the knowledge, attitudes and practices of women regarding skin-lightening products and to quantify the potentially harmful substances in the products used. METHODS: We performed a cross-sectional study among 82 non-Italian women visiting an outpatient facility in Rome, Italy. The women completed a questionnaire on product use, side effects and risk awareness. We performed patch tests among a subgroup of 48 women who presented with contact dermatitis. We also quantified the allergenic and toxic substances in the 14 products reported, using dynamic reaction cell inductively coupled plasma mass spectrometry for metals and high-performance liquid chromatography for hydroquinone and topical corticosteroids. RESULTS: Out of the 82 women, 33 used skin-lightening products; about one fourth of these women were aware of potential risks. Three cosmetic creams and two soaps contained high concentrations of metals (Cr, Ni and Pb); hydroquinone was found in three creams and one oil. The only topical corticosteroid detected was dexamethasone, in one product. More than half of the women in the clinical evaluation had irritant contact dermatitis (i.e., negative response to patch test). CONCLUSIONS: Among immigrant women in Rome, the use of skin-lightening products seems to be fairly common, and some of these products contain potentially hazardous substances. Consumers must be informed of the potential risks, and EU regulations must be more strictly enforced.

A report about the experience of COVID-19 active surveillance of homeless, undocumented people, and shelter staff in two cities of Lazio, Italy.

OBJECTIVE: This study aimed to investigate COVID-19 spread among people experiencing homelessness (PEH), undocumented migrants (UMs), and shelter staff of homeless service sites. Another aim has been to prevent an outbreak among these populations. A San Gallicano Institute's initiative to sustain the health system in helping hard-to-reach populations, very often with no community medical care coverage. SUBJECTS AND METHODS: The San Gallicano Dermatological Institute performed active surveillance for COVID-19 on PEH and UMs living in Rome and Latina, Italy. The screening was performed with two swabs: real-time polymerase chain reaction (RT-PCR) and antigen rapid tests. RESULTS: From June 2020 to January 2022, we performed 10,651 tests: 5,442 molecular swabs and 5,209 antigen rapid tests. A total of 3,503 individuals were screened. The prevalence of SARS-CoV-2 infection was 2.9% among the health and social workers and 5.7% among PEH and UMs. None of the people positive for COVID-19 had symptoms or signs of several illnesses. PEH and UMs who tested positive for COVID-19, asymptomatic or pauci-symptomatic, were transferred to a COVID Hotel or dedicated apartment for further clinical monitoring. CONCLUSIONS: People experiencing homelessness and undocumented migrants are often not registered in the National Health Service and, therefore, difficult to trace. These data could aid in estimating the spread of SARS-CoV-2 among people experiencing homelessness, undocumented migrants, and shelter staff in two Italian cities.

[Risk factors and health effects in the land transport sector]. / Fattori di rischio ed effetti sulla salute nel comparto dei trasporti terrestri.

The transport is a particularly complex sector. There are companies of different size that perform public or private transport, by road or rail, goods or passengers. Companies involved in the sector in Italy are 137,394 with 1,121,203 workers. There are also about 150,000 workers of auxiliary services and an unknown number of workers engaged in intra-companies transportation of goods. The main risk factors are those due to the high probability of accidents, the presence of noise and vibration, ergonomic aspects, work-related stress. Health surveillance is carried out by various organizations and individuals identified by the rules. Medical controls for professional driving licence are performed by local authorities and preventive and periodic health surveillance and medical fitness about occupational risk according to the law (Legislative Decree 81/08) depends on the responsibility of the company physician.

["Back and drive": a prevention and rehabilitation project for public bus drivers]. / Rachide e guida": progetto di prevenzione e riabilitazione per autisti di autobus pubblici.

Back pain is a very common disease among the drivers. The project, based on the assumptions of the Neurocognitive Rehabilitation theory, we propose the prevention of musculoskeletal diseases and the improvement of the health of the subjects, using multiple levels of intervention. In addition to the more traditional prevention interventions it provides theoretical and practical training and education to the perception of the rachis inside job performance, through laboratories and individual treatment as secondary prevention and to facilitate the work. The comparison of three compilations of a questionnaire survey on the perception of the body and the sitting position, given before the course, at its conclusion and at a later time, shows significant change in the subjects' responses, which suggests that the course has changed way of thinking and organizing body and sitting position. Subsequent clinical-epidemiological surveys could test the hypothesis that this has effects of primary and secondary prevention.

[Prevalence of thyroid disease in healthcare workers occupationally exposed to ionizing radiation at the University Hospital of Pisa]. / Prevalenza di patologie tiroidee negli operatori sanitari radioesposti dell'Azienda Ospedaliero Universitaria Pisana.

The study analyzes the prevalence of thyroid disease in 1960 healthcare workers, classified as occupationally exposed to ionizing radiation, who have worked at the University Hospital of Pisa. They underwent a medical surveillance protocol from January 2005 until Mars 2012 at the Operative Unit of Occupational Medicine. A positive history of thyroid disease was found in 221 persons, but only 110 (the 5.61% of the population) developed the disease during or after the occupational exposure. Benign thyroid diseases, found in 93 workers, were in order of frequency: Hashimoto's thyroiditis, nodular disease, Basedow's disease, multinodular goiter, subacute thyroiditis and hypothyroidism. Malignant thyroid diseases were found in 17 workers (the 0.87% of the total population), 15 workers suffered from the papillary histotype and 2 from the medullary histotype.

[Role of reaction times in the health surveillance of a group of complex task workers: public transport drivers]. / Ruolo dei tempi di reazione nel protocollo di sorveglianza sanitaria di una categoria di lavoratori adibiti a mansioni complesse: autisti di mezzi pubblici.

In order to assess the relationship between impaired reaction times and other clinical parameters a study was conducted on a population of public transport drivers, 26 impaired reaction times subjects and 114 controls, matched for age, sex and type of job-task, compared for years of employment, blood pressure, audiometric test, mood disorders, sleepiness and body mass index (BMI). Statistical analysis indicates a close trend to relationship of reaction times impairment with BMI and hypertension; these two variables are also correlated. Our results agree with previous literature: despite the fact that mechanisms underlying the relationship between BMI and cognitive impairments remains unknown, subclinical levels of pathophysiologic changes associated with elevated BMI, could account for the observed differences in our samples. Assessing eligibility in occupational medicine, it could be suitable to evaluate some preventive measures evaluating the efficacy of weight loss on cognitive function and on the ability to work safely.