An undiagnosed pleural effusion with surprising consequences.

We present the case of a 43-year-old Italian woman with a left undiagnosed pleural effusion, which in subsequent months presented a clinically unexpected evolution with the appearance at first of a right wrist tenosynovitis and subsequently a bilateral lung involvement caused by M. Tuberculosis. With this case report, we would like to underline the importance of making a correct diagnosis of any pleural effusion as soon as possible by at least a thoracocentesis. If untreated, tuberculosis may easily disseminate to other organs. Some considerations and suggestions for antibiotic treatment of pleural effusion will also be given, since many antibiotics have some anti-tuberculosis effect and may delay the diagnosis of this infectious disease.

Evaluation of different doses of mashua (Tropaeolum tuberosum) on the reduction of sperm production, motility and morphology in adult male rats.

Mashua is an edible-tuber crop that grows in the Andean region. Folk medicine describes the use of mashua to reduce reproductive function in men. The present study aimed: (i) to determine whether different doses of mashua (0.01, 0.1, 1 and 2 g kg(-1)) produced a dose-response reduction on sperm production and quality; and, (ii) to determine whether these anti-reproductive effects of mashua can be reversible after cessation of treatment (12 and 24 days of recovery time). Mashua-treated rats showed lower values of daily sperm production, epididymal and vas deferens sperm count and sperm motility; meanwhile, mashua increased the percentage of abnormal sperm morphology and epididymal sperm transit rate. The following variables follow a dose-response effect: sperm number in vas deferens, sperm motility and sperm transit rate. In addition, it was demonstrated that the reduction in reproduction function in male rats treated with mashua was reversible after 24 days of recovery time. Finally, lower doses mashua reduces sperm number and quality (motility and morphology), and these adverse effects on male reproductive system may be reversible after 24 days after cessation of the treatment.

Cryptococcal lymphadenitis as a manifestation of immune reconstitution inflammatory syndrome in an HIV-positive patient: a case report and review of the literature.

Cryptococcus neoformans infections are typically associated with T-cell deficiencies, including acquired immunodeficiency syndrome (AIDS). Although highly active antiretroviral therapy (HAART) has strongly reduced AIDS-related opportunistic infections, the restoration and reactivation of CD4+ cells can induce an immune reconstitution inflammatory syndrome (IRIS), consisting in a deregulated inflammatory response to latent infectious pathogens and/or to their residual antigens. Cryptococcal lymphadenitis has occasionally been documented in IRIS. Here we report a case of histology- and culture-negative cryptococcal lymphadenitis associated with IRIS in an adult AIDS patient with a history of disseminated cryptococcosis, after the start of fully adherent HAART. Appropriate diagnosis was established on nested-PCR and sequence analysis of the interspacer region 2 of C. neoformans ribosomal DNA, and detection of slow-growing blastospores in enrichment cultures of fine-needle lymph node aspirate. Review of recent literature and our case findings suggest that IRIS-associated cryptococcal lymphadenitis is more likely the flare up of a latent infection rather than an immunopathological response to residual antigen of unviable cryptococci.

Purification and characterization of an antifungal thaumatin-like protein from Cassia didymobotrya cell culture.

A 23-kDa antifungal thaumatin-like protein was isolated and purified from Cassia didymobotrya (Fres.) cell cultures for the first time. The protein was secreted in the culture medium, but it could be also isolated after elution of whole cells with a 0.5 M CaCl(2) solution. Treatment of the cells with laminarin oligosaccharides or salicylic acid, but not with NaCl, resulted in enhancement of expression of the protein. A rapid purification protocol was used based on cationic exchange chromatography. The protein, with a highly basic character (pI 10), has an exact molecular mass of 23034 Da, as determined by MALDI-ToF mass spectrometry analysis. N-terminal sequencing of the intact polypeptide and the sequencing of two internal tryptic peptides indicated significant identity with other thaumatin-like proteins (TLP). The protein exerted antifungal activity towards some Candida species showing EC(50) values comparable to those of other antifungal TLPs. The collected data lead to classify this TLP as a new PR-5 protein.

Cost determinants of tuberculosis management in a low-prevalence country.

SETTING: Division of respiratory medicine in a specialised infectious disease hospital in Rome, Italy. OBJECTIVE: Retrospective evaluation of tuberculosis (TB) care associated costs in an integrated in- and out-patient management programme. DESIGN: Review of the medical records of 92 human immunodeficiency virus negative TB cases admitted between September 2000 and May 2003. RESULTS: Length of in-hospital stay (45 +/- 35 days) was the major cost determinant, as hospitalisation accounted for almost 80% of the total costs of the case, with fixed bed-per-day charges amounting to 76% of hospital costs. Factors associated with higher costs were chest X-ray score, fever, sputum bacterial load and multidrug resistance (P < 0.05). Cure/treatment completion was achieved in 82% of patients entering the out-patient programme (63% of all cases). Homelessness, age and comorbidities were associated with unfavourable outcomes. CONCLUSIONS: A closely followed hospital-centred protocol carried out in a high-resource setting may produce acceptable cure/completion treatment rates. As a too high fraction of resources invested in TB control goes toward hospital costs, out-patient treatment strategies should be implemented.

[Liver haemangioma: current surgical indications. Our experience]. / Gli angiomi epatici: attuali indicazioni al trattamento chirurgico. Revisione casistica.

Hemangiomas are the more frequent benign liver tumours. Therapeutic approach at these neoplasms is changed in the last years because has resulted that massive haemoperitoneum from a spontaneous rupture of the hemangiomas is a rare occurrence. From a personal review of 124 liver resection performed for traumatic and organic, benign and malignant, pathologies, the Authors present two cases of symptomatic liver haemangioma surgically treated Excluding emergency induced by tumour hemorrhage, actually indications to surgical treatment are controversial. In all patients the right approach is choice by the integrated evaluation of general conditions of the patient, liver functionality and from anatomical location of the neoplasm.

[Appendicectomy: laparoscopic versus open treatment. A case survey]. / Appendicectomia: laparoscopica versus laparotomica. Analisi della casistica.

AIM: Laparoscopy is actually the gold standard approach in many surgical procedures: this consideration is still controversial as to appendectomy. METHODS: From 2000 to 2004 we have performed 257 appendectomies: 51 (20%) in laparoscopic approach. Preoperative diagnosis has been formulated on blood parameters, abdominal or, sometimes, transvaginal ultrasonography. RESULTS: Two hundred and fifty-seven surgical operations, 62 laparoscopic, have been performed for suspicious appendicitis. In the laparoscopic procedures, 11 revealed various diseases without appendicitis. In the remaining 51 cases, appendectomy has been performed totally intra-abdominal and none case turned to laparotomic conversion. Operative times were between 27 and 105 min in the laparoscopic appendectomies (LA) and between 18 and 46 min in the laparotomic appendectomies (OA). In 7.3% of OA and in 3.9% of LA wall infections occurred, as well as abdominal abscesses in 1% of OA and in 4% of LA. Postoperative discharge was after 3.3 days and bowel canalization appeared at 10-18 hours from the surgery, in OA and in LA. CONCLUSIONS: On the basis of these results, the conclusion is drawn that, although discordant opinions in the literature, the advantages of the laparoscopic approach compared to laparotomic approach is still to be demonstrated, both in advantages for the patient and in costs. Laparoscopy is the better surgical technique when the preoperative diagnosis is not clear, particularly in young women or in elderly, in whom a colic neoplasm may be suspected.

Evaluation of the BDProbeTec strand displacement amplification assay in comparison with the AMTD II direct test for rapid diagnosis of tuberculosis.

The BDProbeTec MTB assay for direct detection of Mycobacterium tuberculosis was evaluated in comparison with the AMTD-II assay on 94 samples from different patients with clinical suspicion of tuberculosis. Using a combination of culture on Lowenstein-Jensen medium (with or without preculture in BACTEC 9000) and clinical diagnosis as the standard, BDProbeTec MTB showed high sensitivity and specificity (96.1% and 100%, respectively), similar to AMTD-II (96.1% and 97.1%, respectively), with significantly higher sensitivity than the Ziehl-Neelsen stain for acid-fast bacilli (73%, p < 0.05).

Community-acquired Acinetobacter radioresistens bacteremia in an HIV-positive patient.

We describe the first case of community-acquired bacteremia caused by Acinetobacter radioresistens; the patient was a 32-year-old HIV-positive neutropenic woman. Ambiguous Gram staining and poor biochemical reactivity of blood culture isolates misguided early diagnosis and therapy. Bacterial identification was based on 16S rDNA sequence analysis. A. radioresistens can be considered as a cause of opportunistic infection in immunodeficient patients.

A new strategy for prenatal diagnosis in a sporadic haemophilia B family.

Although the quality of life for haemophiliacs has clearly improved in the last few years, haemophilia still remains a serious disorder justifying prenatal diagnosis (PD) and, if necessary, termination. Because chorionic villus sampling (CVS) is performed in the first trimester of pregnancy, an increasing number of carriers are interested in this test. It has been shown that waiting for the results is particularly distressing for pregnant women, therefore decreasing the diagnostic procedure time can be psychologically helpful. Here we report on PD in a sporadic haemophilia B family based on the direct identification of the pathogenic mutation in a CVS taken at the 12th gestational week. In order to hasten the results, we recovered DNA from a single villus fragment boiled in water and used it directly for PCR reaction. Conformation-sensitive gel electrophoresis (CSGE) was used to detect the mutation in the haemophilia carrier and in the foetus. This approach allowed us to obtain a diagnosis within 24 h of CVS, thus avoiding the long-term psychological effects on the pregnant woman.

Myelodysplasia syndrome and acute myeloid leukemia in patients with congenital neutropenia receiving G-CSF therapy.

Granulocyte colony-stimulating factor (G-CSF) has had a major impact on management of "severe chronic neutropenia," a collective term referring to congenital, idiopathic, or cyclic neutropenia. Almost all patients respond to G-CSF with increased neutrophils, reduced infections, and improved survival. Some responders with congenital neutropenia have developed myelodysplastic syndrome and acute myeloblastic leukemia (MDS/AML), which raises the question of the role of G-CSF in pathogenesis. The Severe Chronic Neutropenia International Registry (SCNIR), Seattle, WA, has data on 696 neutropenic patients, including 352 patients with congenital neutropenia, treated with G-CSF from 1987 to present. Treatment and patient demographic data were analyzed. The 352 congenital patients were observed for a mean of 6 years (range, 0.1-11 years) while being treated. Of these patients, 31 developed MDS/AML, for a crude rate of malignant transformation of nearly 9%. None of the 344 patients with idiopathic or cyclic neutropenia developed MDS/AML. Transformation was associated with acquired marrow cytogenetic clonal changes: 18 patients developed a partial or complete loss of chromosome 7, and 9 patients manifested abnormalities of chromosome 21 (usually trisomy 21). For each yearly treatment interval, the annual rate of MDS/AML development was less than 2%. No significant relationships between age at onset of MDS/AML and patient gender, G-CSF dose, or treatment duration were found (P >.15). In addition to the 31 patients who developed MDS/AML, the SCNIR also has data on 9 additional neutropenic patients whose bone marrow studies show cytogenetic clonal changes but the patients are without transformation to MDS/AML. Although our data does not support a cause-and-effect relationship between development of MDS/AML and G-CSF therapy or other patient demographics, we cannot exclude a direct contribution of G-CSF in the pathogenesis of MDS/AML. This issue is unclear because MDS/AML was not seen in cyclic or idiopathic neutropenia. Improved survival of congenital neutropenia patients receiving G-CSF therapy may allow time for the expression of the leukemic predisposition that characterizes the natural history of these disorders. However, other factors related to G-CSF may also be operative in the setting of congenital neutropenia. (Blood. 2000;96:429-436)

Flow cytometric and functional characterization of AC133+ cells from human umbilical cord blood.

AC133+ cells may represent an alternative source of transplantable haemopoietic progenitor cells to CD34+ cells. Here, we have addressed the characterization of umbilical cord blood (UCB) AC133+ cells and compared their immunophenotypic and functional features with those of UCB CD34+ cells. UCB AC133+ and CD34+ cell fractions were purified by magnetic cell sorting, analysed by flow cytometry, tested for their content in blast cell colony-forming units (CFU-Bl), erythroid and granulocyte-macrophage colony-forming units before and after expansion in the presence of various haemopoietic growth factor combinations. Median AC133+ cell yield was 62.3%, and median AC133+ population purity was 97.9%. AC133+ cells were found to contain significantly more CFU-Bl than CD34+ cells; furthermore, the replating efficiency, i.e. the number of CFU-Bl capable of generating secondary colonies, was higher in the former than in the latter cells. Both AC133+ and CD34+ cells displayed an increased ability to give rise to committed progenitors after 7-day expansion in liquid cultures. These data suggest that the AC133+ cell subset is a heterogeneous pool of immature and more differentiated cells that can be maintained and expanded in well-defined culture conditions. In comparison with CD34+ cells, UCB AC133+ cells appear to contain a higher number of early haemopoietic progenitors.

Acute childhood idiopathic thrombocytopenic purpura: AIEOP consensus guidelines for diagnosis and treatment. Associazione Italiana di Ematologia e Oncologia Pediatrica.

BACKGROUND AND OBJECTIVE: A recent evaluation carried out by the Associazione Italiana di Ematologia e Oncologia Pediatrica (AIEOP) about practice management of acute childhood idiopathic thrombocytopenic purpura (ITP) revealed a remarkable difference of behaviors among the different AIEOP centers. A need for common practice guidelines for this frequent illness arose from this observation. Our aim was to make the diagnosis and treatment of childhood ITP uniform. In the future we will evaluate the influence of these guidelines on practice behaviors. DATA SOURCES AND METHODS: Our main reference was the 1996 document produced by the American Society of Hematology (ASH). Their recommendations were updated with information from literature searched for in the MEDLINE database (June 1996-October 1998); search terms included: thrombocytopenia, ITP, diagnosis, therapy, children. The computerized search retrieved 83 articles. DATA EXTRACTION: the scientific validity of the literature was evaluated by a panel of members using published guidelines. The strength of the evidence was assessed using level of evidence criteria. Only data from level I and level II studies were taken in account. Only one study out of the 83 retrieved articles met these selection criteria and it was considered in addition to the 11 out of 581 articles selected in the ASH ITP guidelines. This preliminary work pointed out each issue about ITP not addressed by clinical studies and all participants in a Consensus Conference expressed their opinion about these issues. RESULTS: Diagnosis is essentially based on history, physical examination, a complete blood count and an examination of the peripheral blood smear. Treatment is recommended taking into account the clinical picture and number of platelets. The main difference between these guidelines and those from ASH are: AIEOP guidelines rely on the opinion of the members of the consensus conference, ASH ones on a panel of experts; therapeutic options include only products available in Italy; the indications to treatment rely more on clinical picture than on platelet number. INTERPRETATION AND CONCLUSIONS: These are explicitly developed, evidence-based practice guidelines to assist Italian pediatricians in making decisions about diagnosis and appropriate health care for patients with acute childhood ITP.

Congenital hypoplastic anaemia in a patient with a new multiple congenital anomalies-mental retardation syndrome.

We report on a girl with congenital hypoplastic anaemia, "coarse" face, generalized hypertrichosis with scalp hypotrichosis, short fifth finger, hypoplastic toenails, and mental retardation. A sister of the proposita, who died at the age of 1 year, had severe congenital anaemia, hypoplastic fingernails, low birth weight, failure to thrive, and repeated upper respiratory tract infections. Based on family history, we suspect that hypoplastic anaemia and the same multiple congenital anomalies-mental retardation syndrome (MCA/MR) were also present in this sister. To the best of our knowledge, this patient represents the first report of congenital hypoplastic anaemia and such a complex MCA/MR syndrome, probably inherited as an autosomal recessive trait.

Diamond-Blackfan anaemia in the Italian population.

Diamond-Blackfan anaemia (DBA) is a congenital disease characterized by defective erythroid progenitor maturation: 30% of patients have congenital malformations. The link between these malformations and defective erythropoiesis is unclear: a defect in a molecule acting both on embryo development and haemopoiesis has been proposed. Inheritance is autosomal dominant in most familial cases, but recessive families have also been reported. Many cases are sporadic. A DBA locus has been mapped on chromosome 19q13.2 (Gustavsson et al, 1997), but several families unlinked to this locus have also been reported (Gustavsson et al, 1998). This paper presents clinical, epidemiological and molecular data for DBA in the Italian population. Segregation analysis of 19q markers in patients with DBA showed exclusion of this locus in 5/12 families with inherited DBA. There was evidently locus heterogeneity for DBA in this population. A new microdeletion was identified in one patient. Other families, in which DBA segregates concordantly with the 19q critical region, suggest incomplete penetrance and expressivity of the DBA gene.