Chronic malaria and hyper-reactive malarial splenomegaly: a retrospective study on the largest series observed in a non-endemic country.

BACKGROUND: Chronic malaria is usually defined as a long-term malarial infection in semi-immune subjects, usually without fever or other acute symptoms. The untreated infection may evolve to hyper-reactive malarial splenomegaly (HMS), a life-threatening complication. This paper describes the largest series of HMS ever observed outside endemic countries, and the clinical outcome after a single anti-malarial treatment. Contrarily to most authors, still reporting the traditional, long-term treatment, regardless possible further exposure, the patients in this series did not receive any further prophylaxis if they were not re-exposed to malaria infection. METHODS: A retrospective, longitudinal study, describing all patients with HMS diagnosed at the Centre for Tropical Diseases of Negrar, Verona, took place over a 25-year period. HMS was defined by a longitudinal spleen diameter ≥16 cm, IgM ≥ 2.5 g/L, anti-malarial antibody titre ≥160, exclusion of other causes of splenomegaly. The short-term (≤6 months) clinical outcome after a single anti-malarial treatment was analysed and so was the long-term outcome of subjects re-exposed to malaria and submitted or not to anti-malarial prophylaxis or intermittent treatment. The association of the outcome with the main independent variables was first assessed with univariate analysis. Logistic regression was also performed. RESULTS: Forty-four subjects with HMS were retrieved. Of those with a short-term follow-up visit (<6 months, median 43 days) available before returning to endemic areas, 20/22 resulted improved/cured, two were unchanged. Of 22 expatriates seen at long-term follow-up after re-exposure, 18 were improved/cured, including eight out of nine who had followed an anti-malarial prophylaxis and 10/13 who had opted for the alternative of an intermittent treatment. CONCLUSION: HMS is the most severe form of chronic malaria. A single anti-malarial treatment is probably adequate to treat HMS in the absence of re-exposure, while an adequate prophylaxis is necessary for patients exposed again to malaria transmission. Intermittent treatment would probably be the only viable approach in endemic countries.

Non-AIDS definings malignancies among human immunodeficiency virus-positive subjects: Epidemiology and outcome after two decades of HAART era.

Highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) infection has been widely available in industrialized countries since 1996; its widespread use determined a dramatic decline in acquired immunodeficiency syndrome (AIDS)-related mortality, and consequently, a significant decrease of AIDS-defining cancers. However the increased mean age of HIV-infected patients, prolonged exposure to environmental and lifestyle cancer risk factors, and coinfection with oncogenic viruses contributed to the emergence of other malignancies that are considered non-AIDS-defining cancers (NADCs) as a relevant fraction of morbidity and mortality among HIV-infected people twenty years after HAART introduction. The role of immunosuppression in the pathogenesis of NADCs is not well defined, and future researches should investigate the etiology of NADCs. In the last years there is a growing evidence that intensive chemotherapy regimens and radiotherapy could be safely administrated to HIV-positive patients while continuing HAART. This requires a multidisciplinary approach and a close co-operation of oncologists and HIV-physicians in order to best manage compliance of patients to treatment and to face drug-related side effects. Here we review the main epidemiological features, risk factors and clinical behavior of the more common NADCs, such as lung cancer, hepatocellular carcinoma, colorectal cancer and anal cancer, Hodgkin's lymphoma and some cutaneous malignancies, focusing also on the current therapeutic approaches and preventive screening strategies.