Disseminated Histoplasmosis as AIDS-presentation. Case Report and Comprehensive Review of Current Literature.

Progressive disseminated histoplasmosis (PDH) is an AIDS-defining illness with a high lethality rate if not promptly treated. The wide range of its possible clinical manifestations represents the main barrier to diagnosis in non-endemic countries. Here we present a case of PDH with haemophagocytic syndrome in a newly diagnosed HIV patient and a comprehensive review of disseminated histoplasmosis focused on epidemiology, clinical features, diagnostic tools and treatment options in HIV-infected patients.

Extensively drug-resistant tuberculosis, Burkina Faso.

Because data from countries in Africa are limited, we measured the proportion of extensively drug-resistant (XDR) tuberculosis (TB) cases among TB patients in Burkina Faso for whom retreatment was failing. Of 34 patients with multidrug-resistant TB, 2 had an XDR TB strain. Second-line TB drugs should be strictly controlled to prevent further XDR TB increase.

Differential diagnosis of cervical mycobacterial lymphadenitis in children.

BACKGROUND AND AIMS: The differential diagnosis between tuberculosis (TB) and lymphadenitis caused by nontuberculous mycobacteria (NTM) in children is often based on epidemiologic and clinical data. The aim of this study was to identify epidemiologic and clinical variables associated with TB lymphadenitis in children attending 2 TB out-patient clinics in northern Italy during a 10-year period. PATIENTS AND METHODS: All children less than 16 years of age attending the study sites suspected of mycobacterial disease from 1999 through 2008 were included in the analysis. Logistic regression was used to evaluate the variables independently associated with TB lymphadenitis. RESULTS: From 299 children diagnosed with mycobacterial disease 121 children (40%) had a clinical diagnosis of cervical mycobacterial lymphadenitis: 38 TB (31%) and 83 NTM lymphadenitis (69%) cases. Increasing age (OR, 1.29; 95% CI, 1.02-1.69; P = 0.04), being foreign born (OR, 11.60; 95% CI, 1.37-114.20; P = 0.02), and having an abnormal chest radiograph (OR, 18.32; 95% CI, 2.37-201.68; P = 0.008) were independently associated with TB lymphadenitis. In the selected model, a 5-year-old foreign born child with cervical lymphadenitis and abnormal findings on chest radiograph has an estimated 0.90 probability of having TB disease. On the other hand, an Italy born child of the same age with cervical lymphadenitis and normal chest radiograph has a 0.04 probability of having TB. CONCLUSION: Epidemiologic and clinical data are useful tools in the differential diagnosis between TB and NTM lymphadenitis when etiologic diagnosis is not available.

Molecular detection of rifampin and isoniazid resistance to guide chronic TB patient management in Burkina Faso.

BACKGROUND: Drug-resistant tuberculosis (DR-TB) is considered a real threat to the achievement of TB control. Testing of mycobacterial culture and testing of drug susceptibility (DST) capacity are limited in resource-poor countries, therefore inadequate treatment may occur, favouring resistance development. We evaluated the molecular assay GenoType MTBDRplus (Hain Lifescience, Germany) in order to detect DR-TB directly in clinical specimens as a means of providing a more accurate management of chronic TB patients in Burkina Faso, a country with a high TB-HIV co-infection prevalence. METHODS: Samples were collected in Burkina Faso where culture and DST are not currently available, and where chronic cases are therefore classified and treated based on clinical evaluation and sputum-smear microscopy results. One hundred and eight chronic TB patients (sputum smear-positive, after completing a re-treatment regimen for pulmonary TB under directly observed therapy) were enrolled in the study from December 2006 to October 2008. Two early morning sputum samples were collected from each patient, immediately frozen, and shipped to Italy in dry ice. Samples were decontaminated, processed for smear microscopy and DNA extraction. Culture was attempted on MGIT960 (Becton Dickinson, Cockeysville, USA) and decontaminated specimens were analyzed for the presence of mutations conferring resistance to rifampin and isoniazid by the molecular assay GenoType MTBDRplus. RESULTS: We obtained a valid molecular test result in 60/61 smear-positive and 47/47 smear-negative patients. Among 108 chronic TB cases we identified patients who (i) harboured rifampin- and isoniazid-susceptible strains (n 24), (ii) were negative for MTB complex DNA (n 24), and (iii) had non-tuberculous mycobacteria infections (n 13). The most represented mutation conferring rifampin-resistance was the D516V substitution in the hotspot region of the rpoB gene (43.8% of cases). Other mutations recognized were the H526D (15.6%), the H526Y (15.6%), and the S531L (9.4%). All isoniazid-resistant cases (n 36) identified by the molecular assay were carrying a S315T substitution in the katG gene. In 41.7% of cases, a mutation affecting the promoter region of the inhA gene was also detected. CONCLUSION: The GenoType MTBDRplus assay performed directly on sputum specimens improves the management of chronic TB cases allowing more appropriate anti-TB regimens.

Mycobacterium szulgai identification by hsp65 gene sequencing in an HIV-positive patient with non-Hodgkin's lymphoma.

Mycobacterium szulgai, described for the first time in 1972, is a rare human pathogen that mainly causes pulmonary non-tubercular mycobacteriosis. We report its isolation and identification from a bronchoalveolar lavage specimen by hsp65 gene sequencing analysis in an HIV-positive patient with non-Hodgkin's lymphoma.

Evaluation of INNO-LiPA assay for direct detection of mycobacteria in pulmonary and extrapulmonary specimens.

The INNO-LiPA Mycobacteria kit has been developed for detecting mycobacteria in liquid and solid cultures through amplification of the 16S-23S rRNA mycobacterial spacer region and the use of species-specific probes. The aim of this study was to verify the possible direct use of the kit on clinical samples. The study was performed retrospectively on a total of 129 specimens (104 pulmonary and 25 extrapulmonary) and the results were compared to those obtained from culture. For pulmonary specimens, the overall clinical sensitivity of INNO-LiPA Mycobacteria kit was 79.5% and its specificity 84.6%. For extrapulmonary samples, the kit had an overall clinical sensitivity of 71.4%. In both cases no false positive results were found.

Mycetoma of the maxillary sinus: endodontic and microbiological correlations.

OBJECTIVE: The purpose was to show the capacity of zinc oxide and eugenol to affect the growth of Aspergillus fumigatus. STUDY DESIGN: An in vitro microbiological analysis was conducted on samples from infected maxillary sinuses and on 3 different endodontic sealers. RESULTS: Tests showed that zinc oxide in solution favors the growth of Aspergillus fumigatus, while eugenol inhibits this growth, even when mixed with zinc oxide powder. This inhibiting effect decreases over time. A reduced effectiveness was demonstrated over a 75-day period. CONCLUSIONS: The hypothesis is that the diminishing concentration of eugenol over time in endodontic sealers allows the zinc oxide to support growth of Aspergillus fumigatus. This is reinforced by clinical experience, where mycetoma has developed years after endodontic therapy with excess sealer in the maxillary sinus.

Determination of HCV genotype by direct sequence analysis of quantitative PCR products.

Hepatitis C virus (HCV) genotyping, combined with quantitative evaluation of HCV RNA, may be beneficial for the management of chronic hepatitis C and in the selection of candidates for interferon treatment. In this study, the COBAS AMPLICOR HCV MONITOR test, a commercially available quantitative assay for HCV RNA, was used. Amplification products obtained from HCV-positive cases were subjected to direct sequencing and genotyping based on seven phylogenetically informative regions within the 5'UTR. Results were compared with those obtained by INNO-LiPA assay. Typing results yielded by both methods were in complete accordance for type and subtype assignment. Twenty-nine of 500 specimens (5.8%) were unclassifiable and belonged to samples with a titer of <70.000 IU, as determined by quantitative assay. Despite this limitation, the overall gain in efficiency, the low rate of test failure and a better resolution of mixed genotypes all constitute a considerable advantage of this system over the commercial hybridization technique for routine clinical laboratory use.