Five-year retrospective Italian multicenter study of visceral leishmaniasis treatment.

The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

Is BCLC algorithm useful in clinical practice? Study on 164 HCC patients.

BACKGROUND/AIMS: The Barcelona Clinic Liver Cancer (BCLC) classification has been recently validated as the best system for treatment guidance for hepatocellular carcinoma (HCC). The aim of this retrospective study is to evaluate the usefulness of BCLC in the treatment of HCC comparing our treatment decision and the BCLC algorithm indications. METHODOLOGY: In 102 patients affected by HCC observed from 1991 to 2002 a retrospective analysis was performed. The choice of treatment was compared with the treatment schedule proposed by BCLC. Whereas the second group of 62 patients observed from 2008 to 2010 was analysed both retrospectively in comparison with the BCLC classification. RESULTS: We found a disagreement in between our decision making and the choices suggested by BCLC. We only found a statistical significance for age and performance status test. In surgical patients the median age and the PST class were lower with a statistically significant p value (0.04 and 0.03, respectively). CONCLUSIONS: The BCLC system would not have changed our decision either in the past, or in present days, especially in surgical indications. Even if the decision making is affected by BCLC, actually that process still needs the support of the experience of each clinical centre involved.

Epidemiology and clinical features of cystic hydatidosis in Western Sicily: a ten-year review.

AIM: To assess retrospectively the epidemiological and clinical aspects of cystic echinococcosis (CE) and to evaluate follow-up and response to treatment in patients affected by CE. METHODS: From January 2000 to December 2010, all patients affected by CE at the Infectious Diseases Units of the University of Catania and of Basilotta Hospital in Nicosia-Enna, were enrolled as participants in the study. Epidemiological, clinical and laboratory data were collected for each patient. Diagnosis of CE was performed using clinical imaging and laboratory parameters. Response to treatment was categorized as follows: "cure" as the disappearance or complete calcification of cyst/s; "improvement" as a reduction in the diameter and/or number of existing cysts; and "impairment" as an increase in the diameter and/or number of existing cyst/s and the onset of relapses (i.e., the onset of new cyst/s and an increase in the diameter of previously existing cyst/s and/or complications. Immunoglobulin E (IgE) titers and eosinophil percentages were evaluated at diagnosis, at six months after the initiation of treatment and again in the case of relapse. Hyper-eosinophilia was defined as an eosinophil percentage of ≥ 6%. RESULTS: Thirty-two patients were diagnosed with CE in our Unit during the research period, with a male-female ratio of 2:1. At the time of diagnosis, 40% of patients presented a single CE cyst. Sixty percent showed multi-organ involvement. The liver-lung localization ratio was 2:1. Patients below the age of 50 at diagnosis were more likely to have multiple cysts (73.7% vs 35.5%, P < 0.05). Regarding treatment, 30 patients were treated medically and 16 surgically. Fourteen patients were treated both medically and surgically. Relapses were seen to be less frequent in patients treated with albendazole before and after surgery. Complete cure or an improvement was achieved in 23 patients. Impairment was observed in one patient. Two patients showed no improvement. Relapses were more frequent in those patients treated before 2005. At diagnosis, 71% of patients were positive for specific CE IgE, and 56.3% showed an eosinophil percentage of ≥ 6%. Patients who were diagnosed with hyper-eosinophilia developed complications more frequently than the other patients, but did not suffer relapses. CONCLUSION: On the basis of our results, we propose cystic echinococcosis screening for family members of patients, appropriate pre- and post-surgery treatment and the assessment of anti-echinococcus IgE titer or eosinophil percentage as a therapy response marker in settings with limited resources.

Does transient elastography (FibroScan®) have a role in decision making in hepatocellular carcinoma?

OBJECTIVES: Portal hypertension has been reported as a negative prognostic factor and a relative contraindication for liver resection. This study considers a possible role of fibrosis evaluation by transient elastography (FibroScan(®)) and its correlation with portal hypertension in patients with cirrhosis, and discusses the use of this technique in planning therapeutic options in patients with hepatocellular carcinoma (HCC). METHODS: A total of 77 patients with cirrhosis, 42 (54.5%) of whom had HCC, were enrolled in this study during 2009-2011. The group included 46 (59.7%) men. The mean age of the sample was 65.2 years. The principle aetiology of disease was hepatitis C virus (HCV)-related cirrhosis (66.2%). Liver function was assessed according to Child-Pugh classification. In all patients liver stiffness (LS) was measured using FibroScan(®). The presence of portal hypertension was indirectly defined as: (i) oesophageal varices detectable on endoscopy; (ii) splenomegaly (increased diameter of the spleen to ≥ 12 cm), or (iii) a platelet count of <100,000 platelets/mm(3). RESULTS: Median LS in all patients was 27.9 kPa. Portal hypertension was recorded as present in 37 patients (48.1%) and absent in 40 patients (51.9%). Median LS values in HCC patients with and without portal hypertension were 29.1 kPa and 19.6 kPa, respectively (r = 0.26, P < 0.04). Liver stiffness was used to implement the Barcelona Clinic Liver Cancer algorithm in decisions about treatment. CONCLUSIONS: The evaluation of liver fibrosis by transient elastography may be useful in the follow-up of patients with cirrhosis and a direct correlation with portal hypertension may aid in the evaluation of surgical risk in patients with HCC and in the choice of alternative therapies.

Treatment induced seroconversion to HBsAb following HBV reactivation in the immunosuppressed haematology and oncology patient: a clinical survey of 5 cases in Catania, Italy.

BACKGROUND: In onco-haematological patients inactive or occult HBV infection may be reactivated as a result of disease-related immuno-suppression and/or chemotherapy with rituximab. OBJECTIVES: This study reports the clinical features of five patients affected by onco-haematological disorders who experienced hepatitis B reactivation. STUDY DESIGN: From 2005 to 2010, five onco-haematological patients with hepatitis B reactivation were admitted to the department of Infectious Diseases, Ferrarotto Hospital, Catania, Italy. RESULTS: At the time of onco-haematological disease diagnosis, 3 patients were HBcAb positive; 1 HBsAb and HBcAb positive; and 1 HBsAg positive, HBV DNA negative. None of the patients received hepatitis B prophylaxis. Reactivation was observed following chemotherapy. One patient was treated with lamivudine, 2 with tenofovir and 2 with telbivudine. Following treatment all patients achieved undetectable HBV DNA and normalization of transaminases. Three patients, those treated with lamivudine and tenofovir, cleared HBsAg and developed protective titres of HBsAb. The remaining patients, who were treated with telbivudine, were HBV DNA negative and HBsAg positive one at 27 months and the other at 5 months of therapy. Treatment thus continued in these patients. CONCLUSION: HBV reactivation can be a severe complication in onco-haematological patients undergoing chemotherapy with rituximab. In our experience all nucleos(t)ide analogues were safe and effective. Three patients seroconverted to HBsAb. This may be as a result of the antivirals enhancing the immune response to HBV. A similar role may also be played by immune recovery following the withdrawal of immune-suppressive treatment. This report confirms the importance of anti-viral prophylaxis in patients with a high risk of HBV reactivation.

A human case of Hymenolepis diminuta in a child from eastern Sicily.

We report a case of Hymenolepis diminuta infection in a 2-year-old child living in a suburban area of Catania, Italy. This case was initially referred to us as Dipylidium caninum infection, which was not cured after being treated twice with mebendazole. However, by analyzing the clinical presentation and stool samples we arrived to the diagnosis of H. diminuta infection. The case presented with atypical allergic manifestations which had never been reported as clinical features of symptomatic H. diminuta infection; remittent fever with abdominal pain, diffuse cutaneous itching, transient thoracic rash, and arthromyalgias. The patient was treated with a 7-day cycle of oral niclosamide, which proved to be safe and effective. This case report emphasizes that a correct parasitological diagnosis requires adequate district laboratories and trained personnel. In addition, we recommend the importance of reporting all H. diminuta infection cases, in order to improve knowledge on epidemiology, clinical presentation, and treatment protocols.

[Association between raised IL-8 serum levels and resistance to combined peg-interferon plus ribavirin therapy in HCV+ active chronic hepatitis]. / associazione tra elevati livelli sierici di IL-8 e resisitenza alla terapia combinata con PEG-interferon + ribavirina nell'epatite cronica attiva HCV+.

IL-8 serum levels were measured in a group of 44 patients affected with Chronic Active Hepatitis (CAH) HCV+ at the beginning and end of peg-interferon plus ribavirin combined therapy. IL-8 levels were compared with those measured in a group of healthy controls. The patients were treated for 12 months, and then followed up for 6 months after the end of the therapy. IL-8 serum levels were detected by ELISA at the beginning and end of the therapy, and then at the end of the follow-up. IL-8 serum levels were significantly more elevated (p<0.01) in CAH HCV+ patients than in the healthy controls. Furthermore, IL-8 serum levels in those patients who subsequently showed a sustained virological response to the therapy, declined on treatment and maintained lower levels than in those who did not respond to therapy. Serum IL-8 can be considered and proposed as a non-invasive and predictive marker of response to combined PEG IFN alpha2b + Ribavirin in CAH HCV +.

Quantitative evaluation of interleukin-12 p40 gene expression in peripheral blood mononuclear cells.

The heterodimeric cytokine IL-12 (composed of a p35 and a p40 subunit) is produced primarily by monocytes, macrophages and B cells. In vitro and in vivo experiments have demonstrated the crucial role of IL-12 in initiating and establishing both innate immunity and T cell-mediated resistance to intracellular pathogens, including Leishmania donovani, Toxoplasma gondii, Listeria monocytogenes, and Mycobacterium tuberculosis. Assessment of cytokine expression has thus become crucial to understand host responses to infections. In this study, by using the reverse transcriptase-real time PCR we developed a highly specific and sensitive assay to quantitatively evaluate IL-12p40 mRNA transcription levels in peripheral blood mononuclear cells (PBMCs) stimulated with PHA vs. unstimulated cells. We also used the ELISA to evaluate bioactive IL-12 release in culture supernatants. We provide evidence that IL-12 p40 mRNA levels were significantly up-regulated in PHA-activated PBMCs. These results were correlated with data of IL-12 levels obtained by ELISA.

Prevalence of HIV and other sexually transmitted diseases among Colombian and Dominican female sex workers living in Catania, Eastern Sicily.

INTRODUCTION: STDs are a significant cause of illness throughout the world. Female sex workers (FSWs) are commonly perceived as belonging to a social group which may engage in high-risk behaviour for acquiring or transmitting HIV and other STDs. The number of immigrant women engaged in sex work has increased in Catania, Sicily, over the last 10 years. This study aims to estimate the prevalence of HIV, HBV, HCV and syphilis among Colombian and Dominican FSWs. METHODS: In total 118 (63.78%) of the FSWs contacted in the course of the project agreed to participate in the study. All women enrolled were counselled on STDs/HIV, safer sex practices and the use of condoms. Blood samples were taken and tested for HIV, HBV, HCV and syphilis. RESULTS: Of the 118 FSWs enrolled, all were negative for both HIV and HCV infection. Two women (1.6%) were positive for hepatitis B (HbsAg). Syphilis testing by VDRL showed three positive results (2.5%), which was confirmed by TPHA. DISCUSSION: This study showed that HIV, HBV, HCV and syphilis seroprevalence among Colombian and Dominican FSWs remains low or very rare. It also indicates that these women were healthy when they arrived in Italy and that condom use with clients is high.

Prevalence of antibodies to HHV-8 in the general population and in individuals at risk for sexually transmitted and blood-borne infections in Catania, Eastern Sicily.

BACKGROUND: Human herpes virus 8 (HHV-8) is the putative infectious agent of multifactorial diseases, such as Kaposi's sarcoma (KS), primary effusion lymphoma and multicentric Castleman's disease. However, its exact mode of action as well as its transmission is still under investigation. Besides, little is known about its seroprevalence in the population. HHV-8 epidemiology has been widely studied all over the world, demonstrating significant differences in distribution among various geographical areas and various population communities. Very few studies of HHV-8 seroprevalence have been conducted in Italy, particularly in Sicily which, along with other Mediterranean areas, is known to have high rates of KS incidence. Between January 2001 and April 2002, 424 patients were consecutively recruited from three treatment facilities. An Infectious Diseases Clinic provided 196 anti-HIV positive patients, both affected by AIDS and not. A further 122 anti-HIV negative intravenous drug users were recruited from drug treatment clinics, while as a control group from the Blood Bank 126 blood donors were recruited. Base-line serum samples were assayed for antibodies to HHV-8 latency-associated nuclear antigen (anti-LANA) by IFA (Viramed Biotech AG, Planneg/Steinkirken--Germany). Anti-HHV-8 antibodies were found in 98 individuals (23.1%). HHV-8 reactivity was more common among anti-HIV positive patients (89/196, 45.4%, 95 C.I. 38.4-52.4) than in IDUs (6/102, 5.9%, 95 C.I. 1.2-16.2) and the control group (3/126, 2.4%, 95 C.I. 0.7-10.1). Overall, anti-HHV-8 antibodies were found in all three groups with large differences between groups.

Slower progression of HIV-1 infection in persons with GB virus C co-infection correlates with an intact T-helper 1 cytokine profile.

BACKGROUND: Progression to AIDS is slower in persons infected with both HIV-1 and GB virus C (GBV-C), also known as hepatitis G virus. OBJECTIVE: To compare clinical, virologic, and immunologic variables in HIV-1-seropositive patients with and without GBV-C co-infection. DESIGN: Subanalysis of a prospective cohort study. SETTING: Institute of Infectious Diseases, University of Catania, Catania, Italy. PATIENTS: 80 asymptomatic HIV-1-seropositive patients. MEASUREMENTS: GBV-C RNA level; plasma HIV-1 viral load; CD4(+) cell counts; and serum levels of interleukin (IL)-2, IL-4, IL-10, and IL-12. RESULTS: At the start of the study, plasma GBV-C RNA was detected in 17 patients (21%). During follow-up, IL-2 and IL-12 levels decreased significantly (P = 0.005 and P = 0.01, respectively) and IL-4 and IL-10 levels increased significantly (P = 0.01 and P = 0.004, respectively) in the GBV-C-negative group but did not change substantially in the GBV-C-positive group. Each measured variable differed significantly between GBV-C-positive and GBV-C-negative groups during follow-up (P < 0.001 for IL-12, IL-4, and IL-10; P = 0.002 for IL-2). CONCLUSION: GB virus C may immunologically interfere with progression of HIV-1 infection to AIDS by maintaining an intact T-helper 1 cytokine profile.

Clinical features of cytomegalic disease in immunocompetent subjects: a 1990-2000 survey.

All cases of Cytomegalvirus-related disease in previously healthy immunocompetent subjects admitted to the University Hospital of Catania between 1990 and 2000 were reviewed. Eighty-one immunocompetent subjects were discharged with a diagnosis of acute cytomegalic disease. Nevertheless, only in 26 cases was the diagnosis confirmed by the determination of the specific immunoglobulin M, viremia or antigenemia. Fifteen subjects presented with a mononucleosis-like syndrome. Eleven subjects had a more severe form of the disease with organ involvement: 3 hepatitis, 3 interstitial pneumonia, 2 aseptic meningitis, 2 ulcerative colitis and 1 peripheral vasculitis. All patients recovered. Two out of 11 severe cases were treated with ganciclovir and 7 with steroids; the remainder received only supportive treatment. Large-scale surveys are required to assess the real impact of Cytomegalovirus disease in immunocompetent subjects and to elaborate guidelines for the management of severe cases.

A placebo-controlled treatment trial of Blastocystis hominis infection with metronidazole.

Blastocystis hominis, previously considered a harmless yeast, is now classified as a protozoan inhabiting the human intestinal tract. The pathogenicity of B. hominis remains controversial and is currently the subject of extensive debate.1- 5 As a result of the uncertainty surrounding the pathogenic role of B. hominis, large-scale treatment trials of B. hominis infection have so far been lacking. In spite of this, several drugs have been reported to be active against the parasite.6-8 The present study was carried out in order to evaluate the efficacy of metronidazole treatment in inducing clinical remission and parasitologic eradication in immunocompetent individuals with B. hominis as the only evident cause of diarrhea.