Infection caused by Sporothrix schenckii: an autochthonous case in Bari, Southern Italy.

An autochthonous case of lymphocutaneous sporotrichosis caused by Sporothrix schenckii is reported. The patient developed skin lesions localized along the lymphatics that appeared after he suffered an injury while collecting wicker canes in marshy water. The fungus was identified as Sporothrix schenckii by MALDI-TOF and sequencing. Phylogenetic analysis was also performed. Low MIC values were detected for all tested echinocandins and azoles except for fluconazole. The patient was treated with itraconazole without significant improvement. A regression of lesions was observed after 3 months of therapy with voriconazole. Few cases of sporotrichosis have been reported in Europe. However, several cases of sporotrichosis have been described in Italy. The incidence of sporotrichosis in Italy may be underestimated and microbiologists, and clinicians must be aware of this fungal infection.

A case report of esophageal actinomycosis in an immunocompetent patient and review of the literature.

Actinomycosis is a rare, chronic and slowly progressive granulomatous disease caused by Actinomyces spp., a Gram-positive anaerobic bacterium that rarely affects the esophagus. Although this infection is uncommon, it has been reported in both immunocompromised and immunocompetent individuals. The infection is often misdiagnosed because it can mimic other pathological conditions (like neoplasms and candidiasis), and Actinomyces is difficult to isolate because it requires specific growth conditions. However, actinomycosis has a favorable course if the microbiological diagnosis is timely. We report a case of esophageal actinomycosis in an immunocompetent 23-year-old man. The patient was admitted with symptoms of gastro-esophageal reflux disease (GERD), that had subsequently worsened. Histological and microbiological investigations revealed the presence of Actinomyces spp. A review of the literature regarding the clinical features, diagnosis, and management of this infection is also discussed.

Paecilomyces lilacinus Keratitis in a Soft Contact Lens Wearer.

We describe a case of keratitis caused by Paecilomyces lilacinus in a contact lens wearer with a history of diabetes.

Update on Acanthamoeba jacobsi genotype T15, including full-length 18S rDNA molecular phylogeny.

Free-living amoebae of the genus Acanthamoeba are worldwide present in natural and artificial environments, and are also clinically important, as causative agents of diseases in humans and other animals. Acanthamoeba comprises several species, historically assigned to one of the three groups based on their cyst morphology, but presently recognized as at least 20 genotypes (T1-T20) on the basis of their nuclear 18S ribosomal RNA (rRNA) gene (18S rDNA) sequences. While strain identification may usually be achieved targeting short (<500 bp) 18S ribosomal DNA (rDNA) fragments, the use of full-length gene sequences (>2200 bp) is necessary for correct genotype description and reliable molecular phylogenetic inference. The genotype T15, corresponding to Acanthamoeba jacobsi, is the only genotype described on the basis of partial sequences (~1500 bp). While this feature does not prevent the correct identification of the strains, having only partial sequences renders the genotype T15 not completely defined and may furthermore affect its position in the Acanthamoeba molecular tree. Here, we complete this gap, by obtaining full-length 18S rDNA sequences from eight A. jacobsi strains, genotype T15. Morphologies and physiological features of isolated strains are reported. Molecular phylogeny based on full 18S rDNA confirms some previous suggestions for a genetic link between T15 and T13, T16, and T19, with T19 as sister-group to T15.

Helicobacter pylori DNA isolation in the stool: an essential pre-requisite for bacterial noninvasive molecular analysis.

PURPOSE: Real-time polymerase chain reaction (RT-PCR) is a widely used technique for bacterial and viral infection diagnosis. Herein, we report our preliminary experience in retrieving H. pylori genetic sequences in stools and analyzing genotypic clarithromycin resistance by RT-PCR (noninvasive), with the aim of comparing this procedure with that performed on biopsy samples (invasive). MATERIALS AND METHODS: After 'in vitro' demonstration of H. pylori DNA detection from pure and stool-mixed bacteria, 52 consecutive patients at the first diagnosis of infection were investigated. DNA was extracted from biopsy tissue and stool samples (THD® Fecal Test, Italy). RT-PCR was performed to detect 23S rRNA encoding bacterial subunit gene and search A2143G, A2142C, A2142G point mutations for clarithromycin resistance assessment. RESULTS: RT-PCR showed H. pylori positive DNA in all infected patients with full concordance between tissue and stool detection (100%). We found A2143G mutation in 10 (19.2%), A2142G in 4 (7.7%) and A2142C in 5 (9.6%) patients; there was a full agreement between biopsy and fecal samples. A2143G was found in all the four A2142G positive cases and in three out of the five A2142C positive strains. Overall clarithromycin resistance rate in our series was 23%. CONCLUSIONS: Despite the need of confirmation on large sample, stool RT-PCR analysis could represent a feasible tool to detect H. pylori DNA sequences and antibiotic resistance point mutations. As compared to tissue molecular analysis, this technique is noninvasive, with potential advantages such as improvement of patient compliance, reduction of diagnostic procedure time/cost and improvement of therapeutic outcome.

Fusariosis in a Patient with Acute Myeloid Leukemia: A Case Report and Review of the Literature.

Fusarium spp. causes infections mostly in patients with prolonged neutropenia. We describe the case of a disseminated Fusarium solani infection in a patient with acute myeloid leukemia which never reached complete remission during its clinical course. The patient had profound neutropenia and developed skin nodules and pneumonia in spite of posaconazole prophylaxis. F. solani was isolated from blood and skin biopsy, being identified from its morphology and by molecular methods. By broth dilution method, the strain was resistant to azoles, including voriconazole and posaconazole, and to echinocandins. MIC to amphotericin B was 4 mg/L. The patient initially seemed to benefit from therapy with voriconazole and amphotericin B, but, neutropenia perduring, his clinical condition deteriorated with fatal outcome. All efforts should be made to determine the correct diagnosis as soon as possible in a neutropenic patient and to treat this infection in a timely way, assuming pathogen susceptibility while tests of antimicrobial susceptibility are pending. A review of the most recent literature on invasive fungal infections is reported.

Colistin-associated Acute Kidney Injury in Severely Ill Patients: A Step Toward a Better Renal Care? A Prospective Cohort Study.

BACKGROUND: Critically ill patients with severe sepsis or septic shock may need relatively high colistin daily doses for efficacy against multidrug-resistant and extensively drug-resistant gram-negative rods. However, acute kidney injury (AKI) may represent a major dose-limiting adverse effect of colistin. We sought to determine AKI occurrence and to identify factors influencing AKI risk in severely ill patients receiving colistin according to a recently proposed dosing strategy. METHODS: A prospective, observational, cohort study involving patients with severe sepsis or septic shock who received colistin was performed. AKI was defined according to Acute Kidney Injury Network criteria. Colistin administration was driven by a modified pharmacokinetics-pharmacodynamics (PK/PD)-based dosing approach. RESULTS: Of 70 patients who received colistin at a median daily dose of 9 million IU (MIU; interquartile range, 5.87-11.1 MIU), 31 (44%) developed AKI. In univariate analysis, age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment (SOFA), score and baseline renal impairment were significantly associated with AKI. Moreover, patients with AKI were less frequently treated with adjuvant ascorbic acid (P = .003). In multivariate analysis, independent predictors of AKI were baseline renal impairment (adjusted hazard ratio, 4.15; 95% confidence interval, 1.9-9.2; P < .001) and age (1.03; 1.0-1.05; P = .028), whereas a strong independent renal-protective role emerged for ascorbic acid (0.27; .12-.57; P < .001). CONCLUSIONS: In severely ill patients receiving colistin according to a PK/PD-driven dosing approach, baseline renal impairment and older age strongly predict AKI occurrence, but concomitant administration of ascorbic acid markedly reduces AKI risk, allowing safer use of colistin.

Alternaria is an Infrequent Cause of Keratitis: A Case Report and Review of the Literature.

OBJECTIVE: To report a case of fungal keratitis caused by Alternaria in a 49-year-old female who developed an acute onset of eye infection after ocular trauma caused by an olive leaf. METHODS: The clinical presentation, microbiological diagnosis, and therapeutic approaches are reported. RESULTS: The patient was referred to our university hospital clinic with corneal abscess in her left eye. Before the start of an empirical antibacterial therapy (both topical and systemic), a swab of the cornea was obtained which at microscopic examination revealed a few fragments of hyphal elements, probably for the paucity of material collected. After one week, the corneal abscess had increased in size, and the corneal stroma was filled with filamentous structures similar to fungal hyphae. Oral and topical voriconazole was administered because of the clinical picture and the response of microbiological laboratory whose examination of the material removed from the anterior chamber showed numerous hyphal fragments identified by culture as Alternaria spp. The corneal abscess healed in two weeks, but the patient now has a corneal scar and is awaiting a corneal transplant. CONCLUSIONS: Ophthalmologists and microbiologists must take fungi into greater consideration as a possible cause of keratitis as they are emerging as the cause of this infectious disease in many countries. Voriconazole spreads well in the eye and is effective in the cure of fungal keratitis including those caused by Alternaria.

Comparison of two methods for the detection of verotoxin producing E.coli in human faecal samples during an outbreak of HUS in Apulia, Southern Italy.

This study evaluated the diagnostic performances of an ELISA method and a molecular method for the detection of verotoxin in faecal samples during an outbreak of haemolytic-uraemic syndrome (HUS) occurring in Apulia, Southern Italy. Two of the 16 faecal samples were positive for verotoxin when analysed by ELISA and resulted PCR positive for stx1, stx2, eaeA and serogroup O26. The other 14 faecal samples resulted negative with both tests. The detection of verotoxin in faecal samples by ELISA is a simple, sensitive, specific and rapid method (2 hours) of considerable utility for routine clinical testing laboratories without access to more specialized diagnostic procedures.

Genotypic heterogeneity based on 18S-rRNA gene sequences among Acanthamoeba isolates from clinical samples in Italy.

Acanthamoeba keratitis (AK) is an ocular disease caused by members of a genus of free-living amoebae and it is associated predominantly with contact lens (CL) use. This study reports 55 cases of AK diagnosed in Italy. Genotype identification was carried out by PCR assay followed by sequence analysis of the 18S rRNA gene using the genus specific primers JDP1 and JDP2. Genotype assignment was based on phenetic analysis of the ASA.S1 subset of the small-subunit rRNA gene sequences. The material has been collected at the Polyclinic Tor Vergata of Rome for a total of 19 isolates and at the Polyclinic Hospital of Bari (36 isolates). Thirty-three out of the 55 genetically characterized isolates were assigned to the genotype T4. Ten isolates were identified as belonging to the genotype T15 thus confirming the first association between the genotype T15 and human amoebic keratitis previously described from the same area. We underline the occurrence of the genotype T3 and T11 identified for the first time in the country.

High-dose, extended-interval colistin administration in critically ill patients: is this the right dosing strategy? A preliminary study.

BACKGROUND: Gram-negative bacteria susceptible only to colistin (COS) are emerging causes of severe nosocomial infections, reviving interest in the use of colistin. However, consensus on the most effective way to administer colistin has not yet been reached. METHODS: All patients who had sepsis due to COS gram-negative bacteria or minimally susceptible gram-negative bacteria and received intravenous colistimethate sodium (CMS) were prospectively enrolled. The CMS dosing schedule was based on a loading dose of 9 MU and a 9-MU twice-daily fractioned maintenance dose, titrated on renal function. For each CMS course, clinical cure, bacteriological clearance, daily serum creatinine clearance, and estimated creatinine clearance were recorded. RESULTS: Twenty-eight infectious episodes due to Acinetobacter baumannii (46.4%), Klebsiella pneumoniae (46.4%), and Pseudomonas aeruginosa (7.2%) were analyzed. The main types of infection were bloodstream infection (64.3%) and ventilator-associated pneumonia (35.7%). Clinical cure was observed in 23 cases (82.1%). Acute kidney injury developed during 5 treatment courses (17.8%), did not require renal replacement therapy, and subsided within 10 days from CMS discontinuation. No correlation was found between variation in serum creatinine level (from baseline to peak) and daily and cumulative doses of CMS, and between variation in serum creatinine level (from baseline to peak) and duration of CMS treatment. CONCLUSIONS: Our study shows that in severe infections due to COS gram-negative bacteria, the high-dose, extended-interval CMS regimen has a high efficacy, without significant renal toxicity.

Microbiological findings in endometrial specimen: our experience.

PURPOSE: Collection of an endometrial specimen for investigating infectious agents in the endometrial cavity is an invasive technique that is at times difficult and painful. In order to avoid the need for endometrial sampling in the cases of suspected or evident endometrial pathology, the aim of this study is to investigate the reliability of cervical cultures for detecting infectious agents present at the endometrial level, comparing the results between cervical cultures and endometrial cultures in women with clinical signs of endometrial inflammation. METHODS: In a prospective diagnostic study, in the period from January 2009 to October 2010, we enrolled 404 women referred to the Department of Obstetrics and Gynecology for diagnostic hysteroscopy. All the patients underwent cervical and endometrial sampling. Cultures for common bacteria, Neisseria gonorrhoeae, yeast, and Ureaplasma urealyticum were performed. RESULTS: The most frequent infectious agents detected at the endometrial level were common bacteria, which accounted for 69% of all cases. In particular, streptococci were found in 27% of cases, and bacteria from intestinal flora (Enterococcus faecalis and Escherichia coli) was recovered in 31% of cases. U. urealyticum was detected in 10% and Mycoplasma in only one patient (0.2% of cases). No cases of N. gonorrhoeae were found. CONCLUSIONS: Cervical culture has a low concordance with endometrial culture. In fact in only 33% of cases was the microorganism found in the cervix the same as that found in the endometrium. These results infer that an endometrial culture is a useful investigative tool for determining the microorganisms in endometrial pathology.

Identification and Characterisation of pST1023 A Mosaic, Multidrug-Resistant and Mobilisable IncR Plasmid.

We report the identification and characterisation of a mosaic, multidrug-resistant and mobilisable IncR plasmid (pST1023) detected in Salmonella ST1023, a monophasic variant 4,[5],12:i: strain of widespread pandemic lineage, reported as a Southern European clone. pST1023 contains exogenous DNA regions, principally gained from pSLT-derivatives and IncI1 plasmids. Acquisition from IncI1 included oriT and nikAB and these conferred the ability to be mobilisable in the presence of a helper plasmid, as we demonstrated with the conjugative plasmids pST1007-1D (IncFII) or pVC1035 (IncC). A sul3-associated class 1 integron, conferring resistance to aminoglycosides, chloramphenicol and trimethoprim-sulphonamides, was also embedded in the acquired IncI1 DNA segment. pST1023 also harboured an additional site-specific recombination system (rfsF/rsdB) and IS elements of the IS1, IS5 (IS903 group) and IS6 families. Four of the six IS26 elements present constituted two pseudo-compound-transposons, named PCT-sil and PCT-Tn10 (identified here for the first time). The study further highlighted the mosaic genetic architecture and the clinical importance of IncR plasmids. Moreover, it provides the first experimental data on the ability of IncR plasmids to be mobilised and their potential role in the horizontal spread of antimicrobial-resistant genes.

A case of sympathetic ophthalmia after a severe acanthamoeba keratitis.

PURPOSE: To report a case of sympathetic ophthalmia (SO) after a severe Acanthamoeba keratitis. METHODS/DESIGN: Interventional case report. RESULTS: A 59-year-old white woman, wearing contact lenses, developed a severe Acanthamoeba keratitis in the left eye, which involved the limbus, and required 8 months of intensive antiamoeba therapy; the condition resolved leaving a painful, phthisical eye with complete corneal neovascularization. Six months later, the patient presented with pain, blurred vision, and photophobia in the right eye. Slitlamp examination of the right eye revealed granulomatous uveitis. On the suspicion of an SO, treatment with high-dose topical and oral corticosteroids and immunosuppressants was started. After 3 months, the eye is stable, with a visual acuity of 20/50, and the patient is taking prednisolone 7.5 mg per day and cyclophosphamide 50 mg per day. CONCLUSIONS: [corrected] Development of SO in the absence of previous trauma or surgery is rare. Our case is the first report of a clinically diagnosed SO after an episode of severe Acanthamoeba keratitis.

Clinical and epidemiological aspects of sporotrichosis: an overview of the cases reported in Europe and in Italy.

Sporotrichosis is a fungal infection occurring worldwide, especially in tropical and sub-tropical areas. We present a brief review of clinical and epidemiological aspects of sporotrichosis, as well as its treatment. Sporotrichosis is rarely reported in Europe and the European Centre of Disease Control does not track its infection rate. To fill this gap, we report a survey of clinical cases described over the past forty years in Europe and in Italy.

Seroprevalence of Chlamydophila pneumoniae in ischaemic heart disease.

We investigated the presence of Chlamydophila pneumoniae antibodies in 125 patients with cardiovascular disease and in 128 controls. C. pneumoniae antibodies were measured by microimmunofluorescence assay. A significantly high prevalence of IgG C. pneumoniae antibodies at titre > or = 8 was found in patients (84%) in comparison to controls (47.6%). Considering as cut-off the IgG titre > or = 32, 52% of patients with coronaropathies and 18.75% of controls resulted positive (p < 0.0001). IgA C. pneumoniae antibodies were found in patients and controls without statistically significant differences. High C. pneumoniae antibodies (titre > or = 256) were found in 11% of patients with acute myocardial infarction (AMI) and in none of the controls. In patients, the percentage of IgG and IgA seropositivity increased with age and decreased in patients aged > 70 years. Only patients with AMI are at risk of having antibodies against C. pneumoniae (OR = 6.69). None of the known risk factors for cardiovascular disease was significantly associated with C. pneumoniae seropositivity IgG. This is the first report in our area on the possible association of C. pneumoniae IgG seropositivity and acute ischemic events.

Helicobacter pylori: Survival in cultivable and non-cultivable form in artificially contaminated Mytilus galloprovincialis.

Several studies report the presence of Helicobacter pylori (H. pylori) in seawater either free or attached to planktonic organism. After considering the role played by plankton in the food chain of most aquatic ecosystems and the possible role that seafood products can assume in the transmission of H. pylori to humans, the aim of this study was to assess the survival of H. pylori in artificially contaminated Mytilus galloprovincialis (M. galloprovincialis). A traditional culture method and a reverse transcriptase-PCR (RT-PCR) assay were employed to detect the mRNA of known virulence factor (VacA) which can be considered use a marker of bacterial viability. The obtained results clearly show that H. pylori is able to survive in artificially contaminated mussels for 6 days (2 days in a cultivable form and 4 days in a non-cultivable form).

Evaluation of Antibiotic Resistance of Helicobacter pylori Strains Isolated in Bari, Southern Italy, in 2017-2018 by Phenotypic and Genotyping Methods.

Objective: Helicobacter pylori antibiotic resistance is a constantly evolving process and local surveillance is warranted to guide clinicians in the choice of therapy. Materials and Methods: Antibiotic susceptibility testing was performed by E-test on 92 H. pylori strains, and resistance to clarithromycin and levofloxacin was also evaluated using a commercially available genotyping method. Results: In naïve patients the resistance to clarithromycin, levofloxacin, and metronidazole was 37.7%, 26.2%, and 16.4%, respectively, significantly lower than the percentage found in treated patients. Concomitant resistance to ≥2 antibiotics was also observed in naïve patients. The A2143G mutation of the 23S-rRNA gene was the most frequently detected, also in naïve patients. The highest minimum inhibitory concentration (MIC)50 value (256 mg/L) was associated with A2142 mutations in all the patients carrying them. For levofloxacin resistance a mutation in codon 87 was detected in 63.9% and in codon 91 in 36.1% of the H. pylori strains, without significant differences in the patients groups. A mutation in codon 87 was associated with the highest MIC50 value (32 mg/L). Conclusions: In our area, a high prevalence of H. pylori primary resistance was detected; these rates were higher in patients who had experienced failure of several courses of therapy. A better knowledge of the local epidemiology of resistance, and the genotypes responsible, will improve the H. pylori eradication rates.

A case of descemet's membrane rupture in a patient affected by Acanthamoeba Keratitis.

OBJECTIVES: We report ultrasound biomicroscopy (UBM) evidence of Descemet's membrane rupture in a patient affected by Acanthamoeba keratitis without corneal perforation. METHODS: A 38-year-old woman who was a habitual wearer of monthly disposable soft contact lens was admitted to our unit for a severe ulcerated corneal abscess. Two days after admission, the patient presented acute stromal hydrops. Ultrasound biomicroscopy examination revealed a Descemet's membrane rupture and an inflammatory reaction in the anterior chamber. Smears with Gram 17 staining and cultural examination revealed the presence of Acanthamoeba. We started specific therapy with propamidine 0.1% and polyhexamethylene biguanide 0.02% eyedrops; we suspended propamidine therapy after 2 weeks form the onset, when the ulcer had recovered, and we continued topical therapy with polyhexamethylene biguanide 0.02% for 6 months. We performed UBM examinations at each control visit during the follow-up that lasted for 18 months. RESULTS: At 1-month's follow-up, the symptoms and corneal alterations had significantly improved, while UBM revealed a spontaneous reattachment of the endothelium-Descemet layer. At 12 months' follow-up, best-corrected visual acuity had improved from hand movements at onset to 20/40, and no sign of intraocular involvement was evidenced. CONCLUSIONS: Acanthamoeba is a ubiquitous protozoan that can affect the cornea, even colonizing the deep layers, causing rupture of the Descemet's membrane. Ultrasound biomicroscopy examination confirmed the severe pathogenicity of this parasite and confirmed that only a prompt diagnosis can limit the damage caused by this affection.

Anisakis pegreffi etiological agent of gastric infections in two Italian women.

Two cases of gastric anisakiasis have been documented in two Italian women who had consumed raw anchovies (Engraulis encrasicolus). The first patient was a 49-year-old woman presenting with epigastric pain and bloody vomiting after ingestion of marinated (vinegar) raw anchovies. During the esophagogastroduodenoscopy (EGDS) a white color worm was detected and extracted from cardia by means of biopsy forceps. The second patient was a 59-year-old woman with irritable bowel syndrome and gastritis, who underwent to periodical EGDSs. In the course of the last EGDS, a white color round worm on antrum and a small polyp on the fundus of the stomach were observed. The two nematodes have been identified as L3 larvae of the genus Anisakis by a light microscope, and as Anisakis pegreffi by polymerase chain reaction-restriction fragment length polymorphism. The molecular identification of the etiological agent at the species level allows to identify what Anisakidae species play a zoonotic role and which are the fish host species.