Clinical score for colorectal cancer patients with lung-limited metastases undergoing surgical resection: Meta-Lung Score

BACKGROUND

Radical resection of isolated lung metastases (LM) from colorectal cancer (CRC) is debated. Like Fong's criteria in liver metastases, our study was meant to assign a clinical prognostic score in patients with LM from CRC, aiming for better surgery selection.

METHODS

We retrospectively analyzed data from 260 CRC patients who underwent curative LM resection from December 2002 to January 2022, verifying the impact of different clinicopathological features on the overall survival (OS).

RESULTS

At the univariate analysis: higher baseline CEA levels (p = 0.0001), disease-free survival less than or equal to 12 months (m) (p = 0.0043), LM size larger than 2 cm (p = 0.0187), multiple resectable nodules (p = 0.0083), and positive nodal status of the primary tumor (p = 0.0011) were associated with worse prognosis. In a Cox regression model, these characteristics retained their independent role for OS (p < 0.0001) and were chosen as criteria to be assigned one point each for clinical risk score. The 5-year survival rate in patients with 0 points was 88%, while no patients with a 5-point score survived at 2 years. Based on the 0-1 vs. 2-5 score range, we obtained a significant difference in median OS: not reached vs. 40.8 months (95 %CI 36 to 87.5), respectively (p < 0.0001) stratifying patients into good and poor prognosis. The prognostic role of the score was also confirmed in terms of median RFS: not reached in 0-1 scored patients vs. 30.5 months (95 %CI 19.4 to 42) in patients with 2-5 scores (p = 0.0006).

CONCLUSIONS

When LM from CRC is resectable, the Meta-Lung Score provides valuable prognostic information. Indeed, while upfront surgery should be considered in patients with scores of 0 to 1, it should be cautiously suggested in patients with scores of 2 to 5, for whom a prognosis comparison between preventive surgery and other treatments should be investigated in prospective randomized clinical trials.

An impressive case of isolated thoracic impalement

Case

A 61-year-old male construction worker was admitted to our Emergency Department due to being impaled in the chest after fall onto the long pole of his cement mixer. He was promptly scanned through the CT then transferred to theatre where unique technique for intubation was utilised prior to performing a Video Assisted Thoracoscopic Surgery exploration and extraction of the foreign object.

Discussion

Impalement injuries are classified into Types I or II depending on the direction of movement of the human body in relation to the foreign object. There currently is no consensus on the best management of chest wall injuries involving impalements. Our case utilised Video Assisted Thoracoscopic Surgery as the dominant method of intervention together with highly skilled anaesthetic preparation.

Conclusion

The combined expert anaesthetic and surgical approach utilised collectively had a role in ensuring the best possible outcome for the patient.

Blood-Derived Systemic Inflammation Markers and Risk of Nodal Failure in Stage Ia Non-Small Cell Lung Cancer: A Multicentric Study

BACKGROUND

Unexpected spread to regional lymph nodes can be found in up to 10% of patients with early stage non-small cell lung cancer (NSCLC), thereby affecting both prognosis and treatment. Given the known relation between systemic inflammation and tumor progression, we sought to evaluate whether blood-derived systemic inflammation markers might help to the predict nodal outcome in patients with stage Ia NSCLC.

METHODS

Preoperative levels of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammation score (SII, platelets × NLR) were collected from 368 patients who underwent curative lung resection for NSCLC. After categorization, inflammatory markers were subjected to logistic regression and time-event analysis in order to find associations with occult nodal spread and postoperative nodal recurrence.

RESULTS

No inflammation marker was associated with the risk of occult nodal spread. SII showed a marginal effect on early nodal recurrence at a quasi-significant level (p = 0.065). However, patients with T1c tumors and elevated PLR and/or SII had significantly shorter times to nodal recurrence compared to T1a/T1b patients (p = 0.001), while patients with T1c and normal PLR/SII did not (p = 0.128).

CONCLUSIONS

blood-derived inflammation markers had no value in the preoperative prediction of nodal status. Nevertheless, our results might suggest a modulating effect of platelet-derived inflammation markers on nodal progression after the resection of tumors larger than 2 cm.

EP-582 Giant bilateral intrathoracic involvement from pseudomyxoma peritonei

A 46 year old male never smoker was referred to the unit for investigation of progressively worsening shortness of breath, 9 months after being treated for pseudomyxoma peritoneum. He had completed 3 cycles of CAPOX chemotherapy followed by total colectomy and hyper-thermic intraperitoneal chemotherapy (HIPEC).

Computed tomography showed very extensive and bulky bilateral intrathoracic disease with large infiltrations in the parietal and visceral pleura, pericardium and diaphragm, suggesting significant intrathoracic extension of pseudomyxoma peritoneum.

Following MDT discussion, pleurectomy and decortication with cytoreductive intent was performed. A pleural mass measuring 5cm was resected, along with drainage of copious amounts of yellow gelatinous material. Extra-pleural dissection was continued up to the apex from the mediastinum and diaphragm. Pericardial tissue was also resected and reconstructed with a vycril mesh. He was discharged home on postoperative day 6 and found to have significant improvement in his symptoms 3 months after surgery.

Chest Wall Silicone Granuloma Following Ruptured Silicone Breast Implant Causes Giant Chest Wall Abscess and Osteomyelitis: The First Report

Silicone breast implant ruptures have been widely reported in the literature. Granuloma formation is a known complication of such ruptures with reported sites including the axillae, limbs, chest wall muscles, and internal organs, such as the lungs and the liver. To the best of our knowledge, there are no reported cases of a silicone granuloma causing osteomyelitis of the sternum and multiple ribs in the absence of infection. We therefore report on the case of an 81-year-old patient who presented with an anterior chest wall discharging sinus tract on the background of a ruptured silicone breast implant. We raise awareness about the potentially devastating complications resulting from a ruptured silicone implant with relevance to cardiothoracic practice.

Image-guided combined ablation and resection in thoracic surgery for the treatment of multiple pulmonary metastases: A preliminary case series

Objectives

To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for patients with multiple pulmonary metastases using intraoperative imaging.

Methods

We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 and January 2020. Procedures were performed in a hybrid operating suite using the ARTIS Pheno cone beam computerized tomography scanner (Siemens Healthineers, Erlangen, German). Patient information included past history of malignancy as well as lesion size, depth, location, and histology result. Surgical complications and length of stay were also recorded.

Results

Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least 1 ablation and 1 wedge resection during the combined procedure. Patient ages ranged from 40 to 66 years and the majority (75%) were men. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 to 24 mm and 21 to 33 mm, respectively, for ablated nodules and 5 to 27 mm and 0 to 22 mm, respectively, for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 to 210 minutes. All cases sustained <10 mL blood loss. There were 2 intraoperative pneumothorax, 1 prevented successful completion of the ablation. One patient required a prolonged period of postoperative physiotherapy and was discharged on day 6. The other patients were discharged on postoperative day 2 or 3. All 5 histology specimens confirmed metastatic disease.

Conclusions

Our hybrid approach provides a minimally invasive and comprehensive personalized therapy for patients with multiple pulmonary metastases under a single general anesthetic. It provides histology-based diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to operating theatre. Emergence of ablation as a treatment for stage 1 non–small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.

Endobronchial Valves in the Management of Persistent Air Leak in Coronavirus Disease 2019

Pneumothorax and persistent air leak are documented complications of severe acute respiratory syndrome coronavirus 2 infection. Patients who fall into this category are often poor candidates for invasive thoracic surgical intervention. Endobronchial valves offer an effective and less invasive treatment option and can successfully treat persistent air leak and support the weaning of patients with severe acute respiratory syndrome coronavirus 2 pneumonia off ventilation.

Results of redo pulmonary metastasectomy

Repeat surgical resection (redo) for pulmonary metastases is a questionable, albeit intriguing topic. We performed an extensive review of the literature, to specifically analyze results of redo pulmonary metastasectomies. We reviewed a total of 3,523 papers. Among these, 2,019 were excluded for redundancy and 1,105 because they were not completely retrievable. Out of 399 eligible papers, 183 had missing information or missing abstract, while 96 lacked data on survival. A total of 120 papers dated from 1991 onwards were finally included. Data regarding mortality, major morbidity, prognostic factors and long-term survivals of the first redo pulmonary metastasectomies were retrieved and analyzed. Homogeneity of data was affected by the lack of guidelines for redo pulmonary metastasectomy and the risks of bias when comparing different studies has to be considered. According to the histology sub-types, redo metastasectomies papers were grouped as: colorectal (n=42), sarcomas (n=36), others (n=20) and all histologies (n=22); the total number of patients was 3,015. Data about chemotherapy were reported in half of the papers, whereas targeted or immunotherapy in 9. None of these associated therapies, except chemotherapy in two records, did significantly modify outcomes. Disease-free interval before the redo procedure was the prevailing prognostic factor and nearly all papers showed a significant correlation between patients’ comorbidities and prognosis. No perioperative mortality was reported, while perioperative major morbidity was overall quite low. Where available, overall survival after the first redo metastasectomy ranged from 10 to 72 months, with a 5-years survival of approximately 50%. The site of first recurrence after the redo procedure was mainly lung. Despite the data retrievable from literature are heterogeneous and confounding, we can state that redo lung metastasectomy is worthwhile when the lesions are resectable and the perioperative risk is low. At present, there are no “non-surgical” therapeutic options to replace redo pulmonary metastasectomies.

Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis

Background

Completion thymectomy may be performed in patients with non-thymomatous refractory myasthenia gravis (MG) to allow a complete and definitive clearance from residual thymic tissue located in the mediastinum or in lower neck. Hereby we present our short- and long-term results of completion thymectomy using subxiphoid video-assisted thoracoscopy.

Methods

Between July 2010 and December 2017, 15 consecutive patients with refractory non-thymomatous myasthenia, 8 women and 7 men with a median age of 44 [interquartile range (IQR) 38.5–53.5] years, underwent video-thoracoscopic completion thymectomy through a subxiphoid approach.

Results

Positron emission tomography (PET) showed mildly avid areas [standardized uptake value (SUV) more than or equal to 1.8] in 11 instances. Median operative time was 106 (IQR, 77–141) minutes. No operative deaths nor major morbidity occurred. Mean 1-day postoperative Visual Analogue Scale value was 2.53±0.63. Median hospital stay was 2 (IQR, 1–3.5) days. A significant decrease of the anti-acetylcholine receptor antibodies was observed after 1 month [median percentage changes −67% (IQR, −39% to −83%)]. Median follow-up was 45 (IQR, 21–58) months. At the most recent follow-up complete stable remission was achieved in 5 patients. Another 9 patients had significant improvement in bulbar and limb function, requiring lower doses of corticosteroids and anticholinesterase drugs. Only one patient remained clinically stable albeit drug doses were reduced. One-month postoperative drop of anti-acetylcholine receptor antibodies was significantly correlated with complete stable remission (P=0.002).

Conclusions

This initial experience confirms that removal of ectopic and residual thymus through a subxiphoid approach can reduce anti-acetylcholine receptor antibody titer correlating to good outcome of refractory MG.

Delayed post-traumatic presentation of severe sternal osteomyelitis: A strong multidisciplinary effort and a novel reconstruction technique for a challenging case

Sternal osteomyelitis is a morbid and challenging condition, which can rarely occur after trauma, with no established consensus over best therapeutic options. In this case, a 47-year-old man with history of intravenous drug use presented 11 weeks after a minor blunt chest trauma with a severe necrotizing osteomyelitis involving sternum, muscles, fascia and subcutaneous tissue and positive blood cultures for Methicillin Sensitive Staphylococcus aureus. Alongside tailored antibiotic therapy, extensive surgical debridement was performed, leaving a full thickness 3 × 4 cm sternal defect and a large skin defect. After 4 weeks of antibiotics and Vacuum-Assisted-Closure pump, a novel reconstruction technique was utilized, with full collaborations of thoracic surgeons, orthopaedic surgeons and plastic surgeons. An autologous tricortical iliac crest bone graft was harvested and shaped to fit the full-thickness sternal defect, while two titanium sigmoid-shaped clavicle plates were used for internal fixation of the autograft. The large skin defect was covered with a pedicled myocutaneous latissimus dorsi flap. Integrity and stability of the chest wall was fully restored, and infection was completely eradicated. No complications occurred and the patient was well at the 18 months follow-up. To the best of our knowledge, this is the first report on autologous iliac crest bone graft in the treatment of sternal osteomyelitis. In this case, it proved to be a viable therapeutic option, providing good long-term clinical and cosmetic results.

Onset and Evolution of Clinically Apparent Myasthenia Gravis After Resection of Non-myasthenic Thymomas

Patients with thymoma and without clinical or electromyographical myasthenic signs may occasionally develop myasthenia several years after thymectomy. Hereby, we investigated the predictors and the evolution of this peculiar disease. We performed a retrospective analysis in 104 consecutive patients who underwent thymectomy between 1987 and 2013 for thymoma without clinical or electromyographic signs of myasthenia gravis. Predictors of post-thymectomy onset of myasthenia gravis were investigated with univariate time-to-disease analysis. Evolution of myasthenia was analyzed with time-to-regression analysis. Eight patients developed late myasthenia gravis after a median period of 33 months from thymectomy. No significant correlation was found for age, gender, Masaoka's stage, and World Health Organization histology. Only high preoperative serum acetylcholine-receptor antibodies titer (>0.3 nmol/L) was significantly associated with post-thymectomy myasthenia gravis at univariate time-to-disease (P = 0.003) analysis. Positron emission tomography was always performed in high-titer patients, and increased metabolic activity was detected in 4 of these patients. Surgical treatment through redo-sternotomy or video-assisted thoracoscopy was performed in these last cases with a remission in all patients after 12, 24, 32 and 48 months, respectively. No patient under medical treatment has yet developed a complete remission. In our study the presence of preoperative high-level serum acetylcholine receptor antibodies was the only factor significantly associated with the development of post-thymectomy myasthenia gravis. The persistence of residual islet of ectopic thymic tissue was one of the causes of the onset of myasthenia and its surgical removal was successful.

A record-breaking lung metastasis from renal cell carcinoma 37 years after nephrectomy

Development of distant metastases from renal cell carcinoma (RCC) is a frequent occurrence and, in nearly 95% of the cases, secondary lesions present within 5 years following nephrectomy. We performed a left pneumonectomy for a peri-hilar lung mass in an 81-year-old man with history of kidney cancer, resected 37 years earlier. Histopathological examination revealed a solitary lung metastasis from RCC, relapsed after an extraordinary 37-year time interval. To the best of our knowledge, this remarkable case represents the longest time interval between radical nephrectomy for RCC and the occurrence of a pulmonary metastasis. After an uneventful post-operative recovery, there are no signs of disease recurrence at a 3-year follow-up. The possibility of a lung metastasis should be taken into account in patients with history of RCC who present with pulmonary nodules, even decades after treatment of the primary neoplasm.

Giant spontaneous herniation of the post-pneumonectomy cavity

Following a pneumonectomy, excessive mediastinal shift can cause rare complications involving the post-pneumonectomy cavity, which can become the seat of herniation of the residual lung and of the heart. We herein report an even more rare event, entailing an impressive herniation of the actual entire post-pneumonectomy cavity through an intercostal space, which developed spontaneously nearly 3 years after surgery. Surgical excision of the hernia sac and repair of the defect with polypropylene mesh provided adequate treatment and good cosmetic results. Postoperative recovery was uneventful and no signs of recurrence have been observed.

1000 cases of tubeless video-assisted thoracic surgery at the Rome Tor Vergata University

In the early 2000s, the ‘Awake Thoracic Surgery Research Group’ at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.

Intrathymic ectopic parathyroid adenoma caused primary hyperparathyroidism with vitamin D deficiency several years after bariatric surgery

Up to 25% of patients with primary hyperparathyroidism have ectopic parathyroid adenoma. A 45-year-old formerly obese woman underwent extended thymectomy for a parathyroid adenoma located in hyperplastic thymic tissue, associated with primary hyperparathyroidism and severe vitamin D deficiency, but normal bone mineral density. At nine months follow-up, all laboratory test results were within normal limits and she presented no symptoms and no recurrence of disease. In this case, autonomous growth of a parathyroid adenoma was reasonably secondary to chronic calcium and vitamin D malabsorption, which often occurs after bariatric surgery for pathologic obesity.

Erythrocyte osmotic resistance recovery after lung volume reduction surgery

OBJECTIVES

Alteration of erythrocyte osmotic resistance, with increment of reticulocytes, is common in emphysema. This fragility is probably due to an altered fatty acid membrane composition from lipid peroxidation, a reaction triggered by the disease-related increment of reactive oxidative species. We analysed the effects of lung volume reduction surgery (LVRS) on this anomaly compared with respiratory rehabilitation (RR) therapy.

METHODS

We retrospectively compared 58 male patients with moderate-to-severe emphysema who underwent LVRS with 56 similar patients who underwent standardized RR. Respiratory function parameters, erythrocyte osmotic resistance and antioxidant enzymes levels were evaluated before and 6 months after treatments.

RESULTS

Significant improvements in respiratory function, exercise capacity, unsaturated fatty acid content (+10.0%, P = 0.035), erythrocyte osmotic resistance (hyperosmolar resistance -21.0%, P = 0.001; hyposmolar resistance -18.0%, P = 0.007) and erythrocyte antioxidant enzymes [superoxide dismutase (SOD) +60.0%, P < 0.001; glutathione peroxidase +39.0%, P = 0.004 and glutathione reductase +24.5%, P = 0.008] were observed after surgery. In the RR group, we did not find any significant improvements in osmotic resistance, although respiratory and functional parameters were significantly improved. Correlation analysis in the surgical group showed that the reduction in residual volume (RV) significantly correlated the normalization of hyperosmotic (P = 0.019) and hyposmotic resistances (P = 0.006), the decrease in the absolute number of reticulocytes (P = 0.037) and increase in SOD (P < 0.001).

CONCLUSIONS

LVRS improved unsaturated fatty acid content, erythrocyte osmotic resistance and levels of erythrocyte antioxidant enzymes compared with RR. Correlations between erythrocyte osmotic resistance and antioxidant intracellular enzymes with RV suggest that reduction in lung hyperinflation with the elimination of inflammatory emphysematous tissue may explain such improvements after surgery.

Focus of human trichinellosis in Papua New Guinea

Human trichinellosis and teniasis (Taenia solium) are meat-borne helminthic infections with a wide distribution throughout the world. However, there is little information on the prevalence of these infections in Papua New Guinea. In 1999, serum samples were collected from 97 people in 6 villages in the remote Bensbach area of Papua New Guinea. Enzyme-linked immunosorbent assay and Western blot analyses were used to detect anti-Trichinella immunoglobulin (Ig) G and anti-cysticercus IgG in this population. The prevalence of Trichinella antibodies among inhabitants of the Bensbach area was 28.9% (28 of 97; 67.8% in men), suggesting a high consumption of poorly cooked meat. The higher prevalence of infection for Trichinella in men compared with women may be explained by the inclination of men to eat undercooked pork while hunting. All serum samples were negative for cysticercus antibodies. This is to our knowledge the first serosurvey showing anti-Trichinella antibodies in a human population living in Papua New Guinea (Australian region).

Horse trichinellosis, an unresolved puzzle

In spite of routine controls to detect Trichinella larvae in horse-meat, human infections due to horse-meat consumption continue to occur in France and Italy. The epidemiology of horse trichinellosis since its discovery in 1975 is outlined, addressing the possible modes of natural transmission to horses, the need to develop more sensitive methods for detecting Trichinella larvae in horses, and the economic impact of horse trichinellosis. Investigations of human outbreaks due to horse-meat consumption have implicated single cases of inadequate veterinary controls on horses imported from non-European Union countries. In particular, most cases of human infection have been attributed to horses imported from Eastern Europe, where pig trichinellosis is re-emerging and the main source of infection in horses.

An expected outbreak of human trichinellosis for the consumption of horsemeat

In late February 1998, an outbreak of human trichinellosis occurred in the town of Piacenza (northern Italy) among 92 persons who had eaten raw horsemeat. The source of infection was a horse imported to the abattoir of Brescia one month previously. Although the horse had been found to be positive for trichinellosis upon routine examination, the head of an uninfected horse was exchanged with the head of the infected animal, which was mistakenly placed on the market.

Failure of mebendazole in the treatment of humans with Trichinella spiralis infection at the stage of encapsulating larvae

Trichinella spiralis larvae infective for laboratory mice were collected from muscle biopsies performed at different times (from 1 day to 16 months) following the end of treatment, indicating the failure of mebendazole to kill Trichinella parasites when they are encapsulating in muscles.

Trichinella pseudospiralis outbreak in France

Four persons became ill with trichinellosis after eating meat from a wild boar hunted in Camargue, France. Nonencapsulated larvae of Trichinella pseudospiralis were detected in meat and muscle biopsy specimens. The diagnoses were confirmed by molecular typing. Surveillance for the emerging T. pseudospiralis should be expanded.

Identification and characterisation of three antigenic proteins from Cryptosporidium parvum sporozoites using a DNA library expressing poly-histidine tagged peptides

To identify antigenic peptides of the parasite Cryptosporidium parvum, an expression library that allows for the production of chimeric proteins fused with a 6-histidine tag was made. The library was screened with C. parvum sporozoite rabbit anti-serum, and three positive clones (sa20, sa35, and sa40) were identified. The corresponding recombinant proteins (SA20, SA35, and SA40) were expressed in Escherichia coli and purified by metal-affinity chromatography. The sequence of sa20 and sa35 clones did not show any homology with known genes or proteins, whereas the 5' end of the sa40 clone showed homology with two previously identified C. parvum sequences. Hybridisations to intact chromosomes fractionated by pulsed-field gel electrophoresis revealed that the sa35 and sa40 sequences are localised on chromosome VII, whereas the sa20 sequence is localised on chromosome VI. Reverse transcriptase-PCR experiments showed the presence of mRNAs for sa35 and sa40 in the oocyst, whereas the sa20 mRNA was undetectable in this stage. The serological response to the three proteins was assayed in C. parvum-immunised rabbits and in immunocompetent individuals with cryptosporidiosis. The Western blot results indicated that rabbits, challenged with a sporozoite crude antigen or with an oocyst crude antigen, were highly responsive to these three antigens. Human serum samples showed a response to the three proteins, although the response to SA20 appeared to be unrelated to a recent C. parvum infection. These results suggest that the SA35 and the SA40 proteins may be useful in detecting C. parvum infections.

Long-term survival of Cryptosporidium parvum oocysts in seawater and in experimentally infected mussels (Mytilus galloprovincialis)

Transmission of infectious oocysts of Cryptosporidium parvum via surface- and drinking-water supplies has been reported and many surface waters flow into the sea, potentially causing runoff of animal-infected faeces. Eating raw mussels is a common practice in many countries, increasing the public's risk of acquiring enteric pathogens. The aims of the present study were to estimate how long C. parvum oocysts remain infectious in artificial seawater, to determine if the oocysts are retained in mussel tissues (Mytilus galloprovincialis), and how long they maintain their infectivity. Oocysts were incubated in artificial seawater at 6-8 degrees C under moderate oxygenation and the infectivity of oocysts was tested five times, over a 12 month period after incubation in seawater, in BALB/c mice. Each pup was inoculated per os with 10(5) oocysts and killed 5 days p.i. Oocysts remained infectious for 1 year. Forty mussels held in an aquarium containing artificial seawater filtered out more than 4 x 10(8) oocysts in a 24 h period. Oocysts were detected in the gill washing up to 3 days p.i., in the haemolymph up to 7 days p.i., and in the intestinal tract up to 14 days p.i. Oocysts collected from the gut of mussels 7 and 14 days p.i. were observed to have infected mice. These results suggest that C. parvum oocysts can survive in seawater for at least 1 year and can be filtered out by benthic mussels, retaining their infectivity up to 14 days, so seawater and molluscs are a potential source of C. parvum infection for humans.

Gastric involvement in AIDS associated cryptosporidiosis

BACKGROUND

Cryptosporidiosis has been shown to be a common cause of diarrhoea in both immunocompetent and immunosuppressed individuals. There are very few data on the distribution of Cryptosporidium parvum along the gastrointestinal tract.

AIMS

To evaluate the location of Cryptosporidium parasites in the digestive tract of patients with AIDS.

METHODS

Gastrointestinal localisation of C parvum was studied in 71 patients with AIDS who underwent upper and/or lower endoscopy with biopsy for chronic diarrhoeal illness and/or other gastrointestinal disorders of unexplained origin.

RESULTS

Twenty four individuals (33.8%) were positive for C parvum, of which 16 (88.9%) had parasites in the gastric epithelium. Most patients with gastric localisation of C parvum did not show specific symptoms indicating the presence of this parasite in the stomach.

CONCLUSIONS

Gastric involvement in AIDS related cryptosporidiosis is more frequent than expected, but no clear correlation between gastric location and related clinical and pathological features was observed.

Identification of a human isolate of Encephalitozoon cuniculi type I from Italy

A microsporidial strain, obtained from a person with AIDS living in Italy was isolated and cultivated on RK13 (rabbit kidney) cell monolayers. Identification at the species level was performed by immunological and molecular methods. Western blot analysis showed that the human isolate and the Encephalitozoon cuniculi reference strain had similar banding patterns. The small subunit rRNA sequence analysis confirmed the identification of the isolate as E. cuniculi, which is a widespread microsporidian species infecting a wide range of natural hosts, including humans. Moreover, based on the sequence of the rDNA internal transcribed spacer region, this isolate was classified as E. cuniculi type I (rabbit strain), previously reported in six persons with AIDS living in Switzerland. These results provide further information on the geographical distribution of E. cuniculi types.

Human outbreak of trichinellosis associated with the consumption of horsemeat in Italy

Trichinellosis is endemic among sylvatic mammals in Italy, though it causes only few infections in humans, usually due to the consumption of pork from pigs grazing in wild areas or from wild boars. Most cases of human trichinellosis in Italy are due to th

Distribution of Trichinella spiralis larvae in muscles from a naturally infected horse

Epidemiological investigations conducted during 10 trichinellosis outbreaks between 1975 and 1994 showed that horse-meat was the probable source of infection. Though hundreds of thousands of horses have been examined at abattoirs in America and Europe to detect Trichinella infection by artificial digestion or trichinelloscopy, an infected horse has never been detected during routine analysis, which consists of examining 1 g of tissue muscle from the diaphragm. In November 1996, a naturally infected horse imported from Romania was detected in Southern Italy. The parasite was identified as Trichinella spiralis by random amplified polymorphic DNA analysis. Artificial digestion of tissue samples from 60 different muscles from 13 different sites of the infected horse carcass showed that M. levator Labii maxillaris, M. hyoideus transversus, and M. buccinator were the 3 most infected muscles. Muscles from the tongue, the masseter, and the diaphragm, which have normally been considered the muscles of choice for diagnosis, were the 4th, 6th and 13th most infected muscles, respectively. When comparing body sites, muscle tissues from the head showed the highest level of infection, followed by muscles from the neck. This finding may explain the negative results that have been obtained in the past during routine examination of the diaphragm of horses.

First outbreak of human trichinellosis caused by Trichinella pseudospiralis

This is the first report of an epidemic of human infection with Trichinella pseudospiralis. An outbreak of trichinellosis affecting 59 individuals, of whom one died, occurred in southern Thailand during 1994-1995. The source of this epidemic was raw pork from a wild pig that was distributed to villagers by a local hunter. The most striking clinical features among 50 individuals who could be followed were muscular swelling, myalgia, and asthenia persisting for > 4 months. These were associated with significant elevations of creatine phosphokinase and lactate dehydrogenase levels. All patients had Trichinella-specific IgG antibodies in an enzyme-linked immunosorbent assay. Muscle biopsies, performed in six cases, showed nonencapsulated, actively migrating Trichinella larvae. Experimental infection of mice with larvae from human biopsies revealed nonencapsulated muscle larvae consistent with T. pseudospiralis. The identification of muscle larvae from a human specimen by random amplified polymorphic DNA analysis confirmed the causative agent to be T. pseudospiralis. Patients seemed to respond best to treatment with albendazole.

Detection of Trichinella spiralis in a horse during routine examination in Italy

Routine examination for Trichinella infection by artificial digestion of 5-g samples of muscle tissue revealed the presence of muscle larvae in one out of 28 horses imported from Romania to an abattoir in Italy. The parasite, identified as Trichinella spiralis by the polymerase chain reaction, showed a reproductive capacity index of 68 in Swiss mice. Light microscope examination of 200 nurse cell-larva complexes showed that 22% of them were calcified and that the capsules of the non-calcified nurse cells were 17.5-27.5 microns (s = 22.67 microns) thick and had very few cellular infiltrates. The serum samples from the parasitologically positive horse and from three other horses of the same stock, from which Trichinella larvae were not recovered by digestion, showed a low level of positivity as determined by ELISA and Western blot analyses using a crude antigen, whereas negative results were observed in both tests when an excretory-secretory antigen was used. The results, together with data from the literature, suggest that the horse had acquired the infection 8-10 months previously and confirm earlier observation obtained from experimental infections, which showed that muscle worm burden and specific circulating antibodies were lost several months after infection.

Clinical cryptosporidiosis and human immunodeficiency virus (HIV)-induced immunosuppression: findings from a longitudinal study of HIV-positive and HIV-negative former injection drug users

The natural history of cryptosporidiosis was investigated during a waterborne outbreak among 1731 members of a drug rehabilitation community in Italy; 19.6% of the members were positive for human immunodeficiency virus (HIV). Demographic and clinical information and pre-outbreak serum samples were available. Clinical data were analyzed, stratifying the study population by HIV serostatus and CD4 cell count. The attack rate of clinical cryptosporidiosis was 13.6% among HIV-negative individuals and 30.7% among HIV-positive individuals, although in the latter, it varied according to CD4 cell count. Clinical symptoms and their duration were also related to CD4 cell count. Chronic symptoms were observed in only 16 individuals (15.4%), who all had <150 CD4 cells at the onset of the illness. Among a systematic sample of 198 individuals, 14.1% already had anti-Cryptosporidium antibodies before the outbreak, and 51.2% developed specific antibodies during the outbreak. The development and clinical manifestations of cryptosporidiosis were strongly influenced by the level of HIV-induced immunosuppression.

[Development of an immunoenzyme test for the diagnosis of human cysticercosis using a heterologous antigen]

Serological tests for the immunodiagnosis of human cysticercosis (an indirect ELISA test) and for the detection of Taenia solium antigen(s) in liquor samples (a sandwich ELISA test) have been developed using a heterologous antigen from the cyst fluid of T. hydatigena. Antibodies to T. solium were detected in 20 Italian subjects out of 113 with cerebral lesions of unknown etiology, and T. solium antigen(s) were detected in three of them, from 1991 to 1994. Case history of the positive patients showed that 17 of them probably acquired the infection in Italy. These results point out that cysticercosis is still present in Italy, and physicians have to consider this helminthic infection in a differential diagnosis.