Detection of hepatitis C virus in an exhumed body identified the origin of a nosocomial transmission that caused multiple fatal diseases.

BACKGROUND: Medico-legal conflicts arise when it is difficult to prove the cause of nosocomial infections. AIM: To report an outbreak of patient-to-patient transmission of hepatitis C virus (HCV) through the repeated use of a multi-dose saline flask during the rinsing of central venous catheters. METHODS: Blood samples were taken from each patient for the comparative analysis of their HCV RNA strains. No samples were available for one patient who died before the investigation started. Despite the known lability of HCV RNA, the body was exhumed four months after burial and postmortem samples were collected. HCV RNA was extracted successfully from liver and spleen samples. Genotyping of all the HCV strains was performed by sequence analysis of the 5'NC untranslated region, the E1 core conserved region and the E1/E2 hypervariable region. FINDINGS: Forensic investigators retraced the route used by two ward nurses, when saline catheter flushes were given to 14 patients with each nurse administering to seven patients. The comparative phylogenetic analysis of all case strains identified the deceased patient as the source of contamination to five patients. CONCLUSIONS: This study highlights the value of sequence analysis as a tool for solving medico-legal conflicts. The High Court of Justice found that a health worker's re-use of a contaminated needle resulted in the nosocomial transmission of HCV.

Urinary JCV-DNA testing during natalizumab treatment may increase accuracy of PML risk stratification.

The risk of progressive multifocal leukoencephalopathy (PML) in patients treated with natalizumab for multiple sclerosis (MS) is a serious concern. The presence of anti-JC virus antibodies is a risk factor for PML development, but 2.5 % of the patients result falsely-negative, while the prognostic relevance of testing JCV-DNA in biological fluids of treated patients is debated. Aim of this work was to evaluate the utility of testing JCV-DNA, together with anti-JCV antibodies, in biological samples of treated patients as a tool for PML risk stratification. 126 subjects from 5 MS Centers in Italy were included in the study. We performed a cross-sectional study in 63 patients testing JCV-DNA in blood, peripheral blood cells and urine. We longitudinally assessed the presence of JCV-DNA in a cohort of 33 subjects, one of which developed PML. We could test retrospectively serum samples from another PML case occurred during natalizumab therapy. Anti-JCV antibodies and urinary JCV-DNA were both tested in 73 patients. No changes in JCV-DNA status occurred during natalizumab treatment. The subject who developed PML in the longitudinal cohort had detectable JCV-DNA in urine at all time-points while serum or blood from both PML patients were always negative before the onset of disease and, in one case, after. Four subjects with JCV-DNA in urine and undetectable anti-JCV antibodies were retested for anti-JCV antibodies and three out of four resulted positive. In conclusion, testing JCV-DNA in urine is complementary to testing anti-JCV antibodies in identifying patients at risk of PML.

Rapid diagnosis of tuberculosis and multidrug resistance with the microscopic observation drug susceptibility assay in Ecuador.

A collaborative project was established between the Alli Causai Foundation in Ambato, Ecuador, and the University of Genoa, Italy, to introduce the microscopic observation drug susceptibility (MODS) assay for the rapid identification of Mycobacterium tuberculosis in Ecuador. A total of 507 samples were evaluated during a 10-month period, and DNA was extracted from each isolate and sent to Genoa for confirmatory molecular analysis. M. tuberculosis was identified in 45 samples by MODS, and drug resistance was observed in approximately 21% of the isolates, with four multidrug-resistant strains detected in two patients.

A case of Cunninghamella bertholettiae rhino-cerebral infection in a leukaemic patient and review of recent published studies.

Cunninghamella bertholletiae infection occurs most frequently in neutropenic patients affected by haematological malignancies, is associated with an unfavourable outcome. We report a case of rhino-mastoidal fungal infection in a leukaemic patient. Bioptical tissue cultures yield the isolation of a mould with typical properties of Cunninghamella species. Liposomal amphotericin B (L-Amb) therapy combined with surgical intervention brought the lesion to recovery. Nevertheless, the patient died 14 days after bone marrow transplantation (BMT) from bacterial sepsis. Mastoiditis was documented at CT-scan. The conditioning regimen probably caused the reactivation of the Cunninghamella infection that led to the patient's fatal outcome; fungal hyphae were detected after autopsy of brain and lung tissue.

Soft-tissue infection with Absidia corymbifera and kidney complications in an AIDS patient.

We describe a case of primary cutaneous Absidia corymbifera infection in an AIDS patient with renal complications. The Sensititre YeastOne panel was adopted to determine antifungal susceptibility and liposomial amphotericin B was used which initially produced a significant clinical response.

Drug resistance testing in PBMCs of HIV infected patients.

HIV infected patients are considered a sort of reservoir having different genetically distinct viral variants (quasispecies), that evolve from the starting virus inoculum. Frequently, during replication, HIV can generate nucleotide differences in the new viral population; such genetic changes may be uninfluential in viral "fitness" (replication capacity) or give the virus some advantages under a selective pressure, due to immune response or drug treatment. The use of potent combination therapy for the treatment of HIV infections has certainly improved the "quality of life" for patients, decreasing the viral load in the plasma (HIV RNA). In our study, we investigated whether detection of drug resistance-related mutations was possible in circulating PBMCs, which represent a sort of genetic archive of viral drug resistances, when the levels of viral RNA were reduced to below 400 or 50 copies/ml, since, generally, plasma samples with more than 1,000 copies/ml of HIV RNA are needed to generate some results. The study was successfully performed sequencing proviral HIV DNA in PBMCs from 32 samples belonging to 25 patients, using a new modified protocol, that showed a good reproduciblity and very interesting data, also in patients with low or without circulating HIV RNA levels.

Prospective evaluation of amplification-boosted ELISA for heat-denatured p24 antigen for diagnosis and monitoring of pediatric human immunodeficiency virus type 1 infection.

The performance in pediatric human immunodeficiency virus type 1 (HIV-1) infection of a signal-amplification boosted ELISA for HIV-1 p24 antigen in plasma after heat-mediated immune complex dissociation was prospectively compared with polymerase chain reaction-based procedures. Diagnostic sensitivity and specificity of the p24 antigen test were 100% and 99.2%, respectively. Quantification revealed RNA in 85.7% and p24 antigen in 87.4% of 230 samples from 25 infected children. Concentrations of these indices in individual samples correlated (P<.0001). Introduction or modification of antiretroviral treatment showed concordant responses of RNA and p24 antigen in 39 (90.7%) of 43 instances. The treatment-induced changes in concentrations of RNA were higher than those of p24 antigen in 11 instances. In 1 instance, however, the concentration change of p24 antigen was greater than that of RNA (P=. 002). Variation of RNA concentrations was more marked than that of p24 antigen (P=.002). The p24 antigen test was equivalent to PCR for diagnosing and monitoring pediatric HIV-1 infection.

Level of human immunodeficiency virus DNA in peripheral blood mononuclear cells correlates with efficacy of antiretroviral therapy.

A novel colorimetric assay was developed and validated for accurate quantitation of human immunodeficiency virus (HIV) DNA in peripheral blood mononuclear cells (PBMCs). We tested 318 sequential samples from 56 subjects, 53 of whom were undergoing dual or triple therapy. Patients were considered responders when viremia levels were below 5, 000 HIV RNA copies/ml. The mean DNA copy numbers for untreated and responder subjects were similar (72 and 75, respectively), while it was 4.54-fold higher for nonresponders (339). This report provides strong evidence that HIV DNA levels in PBMCs correlate with therapeutic efficacy and suggests that DNA quantitation is a useful tool to monitor the decay of the HIV reservoir toward disease remission, especially when viremia is undetectable.

ArchAIDS connects a clinical department and a virological laboratory to automatize the follow up of AIDS patients.

A communication system for the automation of the follow up of AIDS patients set up by DIST at the Molecular Virology Unit in the Advanced Biotechnology Centre of Genova and at the Department of Internal Medicine of the Medical School of Genova is presented. This system includes a distributed database to store both clinical and virological data and a set of procedures to transfer patient data with a complete respect of requirements about completeness and privacy.

A novel and innovative quantitative kinetic software for virological colorimetric assays.

This study addresses the limited range of quantification with colorimetric assays (ELISA) starting from the analysis of color production in a reference external curve. An automatic ELISA management software, designated Quanti-Kin Detection System (QKDS) is described, which retains the sensitivity of the end-point reading and extends the dynamic range up to five logarithms with mathematical interpretation of color production. The QKDS software is a generic system suitable for different types of ELISA with substrate incubation at room temperature, does not require dedicated instruments, performs accurate quantification (including assay quality control) and has a user friendly interface. Specific applications were developed for three types of analytes: antibodies, viral antigens and nucleic acids. Data are presented on three representative QKDS applications to HIV antibodies, p24 antigen and proviral DNA kits. The precision of quantification is strictly correlated with the precision of the kit; however, for almost all samples with known analyte amount, the error percentage was below 10%, only for two cases in quantification of HIV proviral DNA the error percentage was around 25%. The necessity for a wide quantification range has been demonstrated by measuring clinical samples, which showed a distribution in all possible quantification ranges for all kits.

Monitoring antiretroviral activity using ICDp24 and CD4 counts in HIV infection.

The fluctuations of HIV-1 p24 antigen concentration have been monitored in the follow-up of 118 subjects in different clinical stages and compared to their CD4 cell count; 104 patients received antiretroviral therapy. Persistent (65%) or sporadic (28%) antigenaemia has been detected in most patients in different clinical stages. The variations of the p24 Ag level are significantly correlated with the CD4 cell count and therapy administration (P = 0.0001). In patients with relatively conserved immune function (CDC II and III), antiretroviral therapy shows the best efficacy and can be efficiently monitored by p24 and CD4 surrogate markers. The data here suggest that although the informative value of p24 Ag is not representative of an AIDS-defining event, it can be used as a short-term and relatively inexpensive virological marker of antiviral activity in vivo, to support the routine management of patients.

Application of neural networks to the follow-up of AIDS patients.

The present work aims to obtain groups of patients with similar profiles of p24 antigen concentration and of CD4+ cell counts. These two markers were chosen because their evaluation represents a significant step in the clinical follow up of HIV-1 infected subjects. The classifications were obtained by a Kohonen neural net trained in three ways: with p24 antigen profiles only, with CD4+ cell count profiles only and with both sets of profiles. The results show that the clustering fashion of the two parameters closely resembles the clustering fashion of CD4+ only rather than the one of p24Ag, both with reference to cluster formation and with reference to distance among clusters.

Single-step PCR in molecular diagnosis of hepatitis C virus infection.

The diagnostic utility of two PCR systems and three PCR detection methods for hepatitis C virus (HCV) RNA was evaluated in serum samples. A nested PCR was considered the reference assay and was compared with two single-step PCR methods: the first is based on the detection of PCR products by liquid hybridization with a 32P-end-labeled probe, and the second is the Roche Amplicor colorimetric assay using microwell plate hybridization with a specific nucleic acid probe. Using the Pelicheck HCV RNA Eurohep genotype 1 proficiency panel, our laboratory achieved medium-high levels of performance with all three methods. The highest sensitivity was, however, observed with the isotopic single-step PCR (ss-PCR) method. The analytical sensitivity of ss-PCR with isotopic detection and ss-PCR with colorimetric detection was identical to that of nested PCR, with a 100% result concordance. Comparison of ss-PCR with enzyme-linked immunosorbent and RIBA assays in the analysis of clinical samples showed a high concordance. ss-PCR methods appear more suitable for diagnostic application. Nevertheless, HCV RNA PCR cannot be considered a screening assay; it should be requested in the presence of reactive serology or specific clinical symptomatology with altered liver parameters, and it is a potential tool for the follow-up of patients with HCV infection.

HTLV type IIIB infection of human thymic epithelial cells: viral expression correlates with the induction of NF-kappa B-binding activity in cells activated by cell adhesion.

Productive infection by the LAV strain has been demonstrated in T cell precursors at different stages of intrathymic development, while viral replication in thymic epithelial cells is still controversial. In this article we show that epithelial cell cultures derived from the medullary component of normal thymus are infectable by HTLV-IIIB virus through cell-free and lymphoid-mediated transmission. Free virus inoculum results in the integration of proviral copies undergoing poor replication, whereas lymphoid-mediated transmission leads to substantial viral expression and the production of viral progeny able to secondary infect lymphoid cells. Interleukin 6 production and phenotype changes (increased expression of MHC class I and ICAM-1) were induced in TE cells by contact with free virus or by adhesion to infected lymphoid cells. By contrast, NF-kappa B-binding activity on the HIV-1 LTR kappa B enhancer element was upregulated only by contact with infected lymphoid cells, but not with virus. The viral replication observed in TE cells after lymphoid-mediated transmission correlates with the upregulation of NF-kappa B-binding activity. Interleukin 6 increased production and phenotype changes and increased NF-kappa B-binding activity were also induced by adhesion to uninfected lymphoid cells, demonstrating that lymphoepithelial cell contacts can activate TE cells. These results demonstrate that thymic epithelial cells are permissive to HIV infection and that viral replication in this cell lineage can be modulated by intracellular signals delivered by adhesive contacts.

Objective evaluation of two markers of HIV-1 infection (p24 antigen concentration and CD4+ cell counts) by a self organizing neural network.

The aim of the present work is to obtain groups of patients with similar profiles of p24 antigen concentration and of CD4+ cell counts. These two markers were chosen because their evaluation represents a significant step in the clinical follow up of HIV-1 infected subjects. The detection methods for p24 antigen concentration and for CD4+ cell counts are well assessed and guarantee easy reproducibility of data obtained in different laboratories. A set of observations with the same time intervals were derived from a continuous function obtained for each patient by a back-propagation neural net trained on the raw data from the patient. The classifications were obtained by a Kohonen neural net trained in three ways: with p24 antigen profiles only, with CD4+ cell count profiles only and with both sets of profiles. The results show that the clustering fashion of the two parameters closely resembles the clustering fashion of CD4+ only, rather than that of p24Ag, both with reference to cluster formation and with reference to distances between clusters.

HIV-1 spreads from lymphocytes to normal human keratinocytes suitable for autologous and allogenic transplantation.

Normal human keratinocytes can reconstitute in vitro cohesive sheets of epithelium suitable for grafting onto patients. Despite the widespread use of autografts and allografts, no data are yet available on productive infection by human immunodeficiency virus (HIV-1) of human keratinocytes. To address this point, we challenged keratinocytes at the second passage of culture with HTLV-IIIB virus by cell-free and cell-mediated inoculum. Viral entry was not achieved by cell-free inoculum, thus demonstrating that cultured keratinocytes do not provide the membrane requirements for viral binding and/or internalization. By contrast, the cell-mediated inoculum overcame specific receptor constraints, leading to viral integration and productive infection. The p24gag viral protein was transiently released in the culture supernatant, although at low level. The viral progeny produced by infected keratinocytes was rescued and amplified by co-culture experiments performed with the HIV-1 high sensitive CEM-SS human T-cell line. Viral integration, p24gag production, and secondary transmission to lymphoid cells was further confirmed with keratinocytes infected at the fourth passage of culture. Taken together, our results demonstrate that cultured keratinocytes can be infected by HTLV-IIIB virus, which can be maintained in semi-latent form for several passages after inoculum and rescued to full replication by a proper target. The in vitro demonstration of lympho-epithelial HIV-1 spreadings warns against the use of inappropriately screened biopsies for the preparation of skin grafts.