[Imported dengue in two tertiary Italian hospitals: Use of rapid diagnostic tests]

Dengue fever is growing at a global level both as number of cases and as geographic area of endemicity. Italy is not in endemic area, but the competent vector Aedes albopictus is widespread in this country, so that the possibility of introduction of the infection cannot be ruled out. We retrospectively collected demographic, clinical, and laboratory data about consecutive cases diagnosed in Torino and Negrar-Verona in the period 2010-2015. One hundred thirteen cases of dengue were observed, with an increasing trend during years. The infection was imported mostly from south-east Asia, but the risk appears to be higher in Latin America. More than half of the patients were admitted to the hospital but only one case of severe dengue was observed. Many patients presented after the resolution of symptoms. Rapid diagnostic tests were done in the majority of patients and allowed a diagnosis both in the acute (NS1 antigen) and convalescent (IgMantibodies) phases of the disease. An early diagnosis is paramount to avoid the spreading of the infection.

A short course of pegylated interferon-alpha in acute HCV hepatitis

Acute hepatitis C virus (HCV) infection evolves to chronicity in 50-84% cases. Treatment with interferon-alpha (IFN-alpha) was repeatedly found to provide sustained cure rates higher than that in chronic HCV infection, but the optimal treatment strategy has not yet been defined. In a multicentre open-label study, we investigated the therapeutic performance of a short course of pegylated (peg) IFN-alpha in patients with acute HCV hepatitis. Peg IFN-alpha2b, 1.0-1.5 micro g/kg weekly, was administered for 12 weeks. Forty-six patients were enrolled; 26 of them were intravenous drug users. Eleven patients had jaundice. Treatment was started within 1-90 days from the peak alanine aminotransferase. Treatment was well tolerated with a single dropout (2%). Thirty-three of 46 patients (72%) had a sustained virological response (SVR) after a 6 months post-treatment follow-up, 8 (17%) relapsed after treatment and 4 were nonresponders (9%). A lower peak viraemia, receiving at least 1.2 micro g/kg of peg IFN-alpha, and a negative HCV-RNA at week 4 and week 12 were predictors of SVR. Thus, in patients with early (week 4) viral response, a short course of peg IFN-alpha at a weekly dose >1.2 micro g/kg, may be a valuable option for the treatment of acute HCV hepatitis.

A randomized trial of pegylated-interferon-alpha2a plus ribavirin with or without amantadine in the re-treatment of patients with chronic hepatitis C not responding to standard interferon and ribavirin

BACKGROUND

There is yet no established treatment for chronic hepatitis C patients non-responder to standard interferon and ribavirin.

AIM

To evaluate efficacy and safety of pegylated-interferon-alpha2a plus ribavirin with or without amantadine in such patients.

METHODS

161 non-responders to standard interferon and ribavirin were randomized into two groups: 81 patients (Group 1) were given weekly Peg-IFN-alpha2a 180 microg plus ribavirin 1,000-1,200 mg/daily for 12 months, 80 patients (Group 2) received weekly Peg-IFN-alpha2a 180 microg plus ribavirin 1,000-1,200 mg/daily and amantadine 200 mg/daily for 12 months.

RESULTS

At the end of follow-up, HCV-RNA was negative in 29.6% of Group 1 and in 21.2% of Group 2 patients (P = 0.22). Patients with genotypes 1 and 4 responded better to bi-therapy (21.7%) than to triple therapy (17.3%, P = 0.5) while among patients with genotypes 2 and 3 there was a trend towards a higher sustained virological response rate when retreated with triple treatment (80% vs. 75%, P = 0.82). On multivariate analysis, genotype 1 or 4, high body mass index and >20% reduction of Peg-interferon were associated with the treatment failure.

CONCLUSIONS

The addition of amantadine does not improve the overall SVR rate in non-responder patients retreated with Peg-IFN and ribavirin; however, about 30% of non-responders may achieve a sustained response, in particular patients with genotypes 2 and 3 show a high SVR (75%).

Conscious sedation during endoscopic retrograde colangiopancreatography: implementation of SIED-SIAARTI-ANOTE guidelines in Belluno Hospital

AIM

In this study we describe the results of adoption of local guidelines for conscious sedation (CS) during endoscopic-retrograde-cholangiopancreatography (ERCP) in Belluno Hospital. Local guidelines were created referring to SIED-SIAARTI-ANOTE guidelines for CS in gastrointestinal endoscopy.

METHODS

Between January 2002 and February 2004, 300 ERCPs to be performed under CS have been scheduled. According to local guidelines CS was performed by the gastroenterologist assisted by an anesthesia nurse. An anesthesiologist was always on call in the intensive care unit (ICU) for emergencies and could be on the site in less than 5 min.

RESULTS

In 278 patients the procedure was performed safely and effectively by the gastroenterologist without any anesthesiological assistance. At follow-up controls patients had either positive or no recollection of the procedure. An anesthesiologist was called in 13 cases to perform deep sedation and in 9 cases to deal with undesired effects (arterial hypertension in 5 patients, 1 episode of bradycardia, 1 of ventricular tachycardia, 1 of atrial fibrillation and 1 of hypoxia).

CONCLUSION

In our experience, CS during ERCP can be safely performed autonomously by a gastroenterologist in the majority of cases. Drug prescription protocol and the presence of an anesthesia nurse create ideal conditions for the operator, patient comfort and good results with a low incidence of undesired events and few calls for the anesthesiologist. To allow safe and effective performance of CS, the Department of Anesthesia should promote the in-service training and up dating of gastroenterologists and anesthesia nurses.

Interferon and amantadine in combination as initial treatment for chronic hepatitis C patients

BACKGROUND/AIMS

To evaluate the efficacy and tolerance of amantadine in combination with interferon in the treatment of chronic hepatitis C.

METHODS

Multi-centre trial including 180 chronic hepatitis C patients without cirrhosis, randomly enrolled to receive interferon 6 MU every other day for 6 months followed by 3 MU for further 6 months (group A, 90 patients), or the same schedule plus amantadine 200 mg/day (group B, 90 patients). Primary end-point was a sustained virological and biochemical response, secondary end-points were on-treatment (third month) and end-of-treatment response rates.

RESULTS

The two groups had similar demographic, biochemical and virological characteristics. A sustained response after 6 months follow-up was observed in 17% of group A and 24% of group B patients (P not significant), an end-of-treatment response was observed in 37% in group A and 47% in group B (P not significant), an on-treatment response was observed in 46% in group A and 61% in group B patients (P < 0.05). No major side effects due to amantadine administration were observed.

CONCLUSIONS

Adding amantadine to interferon did not improve the sustained treatment efficacy. However, the rate of early response at the third month of therapy was significantly higher in the combination therapy group.

A randomized 4-arm multicenter study of interferon alfa-2b plus ribavirin in the treatment of patients with chronic hepatitis C not responding to interferon alone

To determine whether a higher dosage of interferon (IFN) associated with ribavirin and/or prolonged time of administration may improve therapeutic efficacy, we conducted a 4-arm randomized trial on patients with chronic hepatitis C not responding to one or more previous treatment courses with IFN monotherapy. Group 1 (n = 139) received 3 million units (MU) IFN-alpha2b 3 times a week (t.i.w.) plus ribavirin 1,000 mg/d for 12 months; group 2 (n = 162) received 5 MU t.i.w. plus ribavirin for 12 months; group 3 (n = 142) received 3 MU t.i.w. plus ribavirin for 6 months; and group 4 (n = 151) received 5 MU t.i.w. plus ribavirin for 6 months. The primary end point was hepatitis C virus (HCV)-RNA clearance at the end of 6-month follow-up. HCV-RNA was negative in 15% of group 1, 23% of group 2, 11% of group 3, 16% of group 4 (group 2 vs. group 3, P =.04). Among patients with genotypes 1 and 4, sustained response was significantly higher in group 2 vs. group 3 (18% vs. 7%, P =.03; group 1 = 9%, group 4 = 12%, P = not significant [NS]). In patients with genotypes 2 and 3, sustained virologic response was not affected by the different regimens (group 1 = 32%, group 2 = 30%, group 3 = 30%, group 4 = 35%, P = NS). In conclusion, about 23% of nonresponders to IFN monotherapy may achieve a sustained response if re-treated by 5 MU t.i.w. IFN plus ribavirin 1,000 mg/d for 1 year. Patients with genotype 1 should receive a high dosage of IFN plus ribavirin for 12 months, whereas therapy for patients with genotype 2 or 3 should be less aggressive.

Treatment with interferon-alpha2b of naive non-cirrhotic patients with chronic hepatitis C according to viraemia and genotype. Results of a randomized multicentre study. The North West Italian Hepatological Group

OBJECTIVE

To establish whether tailoring the dosage of interferon (IFN)-alpha2b in non-cirrhotic naive patients with chronic hepatitis C according to hepatitis C virus (HCV) genotype and viraemic level improves the rate of sustained response (normal alanine aminotransferase values and HCV-RNA negativity 6 months after the end of therapy).

PATIENTS

A total of 538 consecutively collected HCV-positive patients with non-cirrhotic chronic hepatitis who had not been previously treated.

METHODS

Quantitative viraemia and genotype were determined in each patient by a core laboratory. The patients were randomized to: Group 1, 86 patients with genotype non-1 and viraemia < 1,000,000 HCV genome equivalents/ml (GenEq/ml) treated with 3 Million Units (MU) IFN three times weekly (t.i.w.) for 1 year; Group 2, 42 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 3 MU IFN t.i.w. for 1 year; Group 3, 46 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 5 MU IFN t.i.w. for 1 year; Group 4, 85 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 5, 88 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN t.i.w. for 1 year; Group 6, 94 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 7, 97 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN daily for 2 months followed by 5 MU t.i.w. for a further 10 months.

RESULTS

According to an intention-to-treat analysis, a sustained virological response (negative HCV-RNA by polymerase chain reaction 6 months after the end of therapy) was observed in 42% of Group 1 patients, in 21% of Group 2 patients versus 24% of Group 3 patients [P = not significant (NS)], in 28% of Group 4 patients versus 35% of Group 5 patients (P = NS), and in 8.5% of Group 6 patients versus 12% of Group 7 patients (P = NS).

CONCLUSIONS

Even though a trend towards a therapeutic improvement is observed, the adoption of more aggressive IFN protocols, such as induction therapy, does not appear to significantly improve the rate of sustained response in patients with chronic hepatitis C associated with HCV genotype 1 and highly viraemic levels compared with standard therapy. Moreover, patients with only one unfavourable predictive factor (genotype 1 or high viraemia) do not gain major therapeutic benefits when treated with high doses of IFN.

Warthin's tumour in the parotid gland (an inflammatory or a neoplastic disease?)

Warthin's tumour has always been considered a peculiar neoplasm with specific anatomico-pathological characteristics. In this study we argue that it should not be considered a true neoplasm but simply an inflammatory process which is triggered by the indiscriminate use of tobacco and involves the parotid duct. In the 10 cases treated in our department, Warthin's tumour has predominantly affected males (9:1) and heavy smokers. Our treatment of choice has been enucleoresection. The results have been satisfactory, with no complications such as salivary fistula or permanent lesions of the facial nerve. In two subjects, treated by enucleoresection, there was a pleomorphic adenoma: in one on the same side as previous surgery performed two years earlier and, in the second, in the contralateral gland 4 years after surgery. Both patients, who underwent total parotidectomy, recovered perfectly without complications. Smoking appears to be involved in the development of Warthin's tumour and might be regarded as an inflammatory reaction to smoking or to ionising radiation. Ultrasound and FNAB are necessary for planning the correct surgical strategy, and enucleoresection, in our opinion, is the treatment of choice.

Hepatitis C virus genotypes in a non-cirrhotic Italian population with chronic hepatitis C: correlation with clinical, virological and histological parameters. Results of a prospective multicentre study

To identify correlations between the distribution of hepatitis C virus (HCV) genotypes and demographic, pathological and virological parameters of HCV-infected patients, we prospectively recruited 650 patients with biopsy-proven chronic hepatitis C without histological aspects of cirrhosis; none had been treated with antiviral therapy. Data regarding gender, age, mode of HCV transmission, alanine aminotransferase (ALT) and HCV RNA levels, immunoglobulin M (IgM) anticore values, liver histology and histological activity were obtained from each patient and correlated on multivariate analysis with infecting HCV genotype. Fifty-five per cent of the patients were infected with HCV genotype 1, 20% with HCV genotype 2, 18% with HCV genotype 3 and 7% with HCV genotype 4. Non-transfusional HCV transmission, low ALT levels, IgM anticore reactivity and a low histological grading score were independent variables associated with HCV genotype 1. Older age, female gender, post-transfusional transmission and a high histological grading score were related to HCV genotype 2, whilst younger age, history of current/previous drug abuse, high ALT values, low IgM anticore reactivity and high viraemic levels were associated with HCV genotype 3. History of illicit use of intravenous drugs and low HCV RNA levels were the only independent variables correlated with HCV genotype 4. Genotype 1 remains predominant in Italy but the prevalence of HCV genotypes is changing in relation to age and mode of transmission: Italian patients with HCV genotype 3 are younger and exhibit higher levels of ALT and HCV RNA than patients with other genotypes.

Interferon alpha-2B and ribavirin in combination for patients with chronic hepatitis C who failed to respond to, or relapsed after, interferon alpha therapy: a randomized trial

PURPOSE

To assess the efficacy of interferon alpha-2b and ribavirin in combination in the treatment of patients with chronic hepatitis C who had either failed to respond to therapy with interferon alpha (nonresponders), or who had relapsed after interferon therapy (relapsers).

SUBJECTS AND METHODS

Four hundred patients with chronic hepatitis C (200 nonresponders and 200 relapsers) were randomly assigned in equal numbers to receive either subcutaneous administration of recombinant interferon alpha-2b (3 million units three times per week) and ribavirin (1,000 to 1,200 mg/daily orally) or interferon alpha-2b alone (6 million units three times per week). Both ribavirin and interferon alpha-2b were given for 24 weeks. The patients were then followed for an additional 24 weeks.

RESULTS

At the end of the treatment period, normalization of serum alanine aminotransferase levels and absence of hepatitis C virus RNA were seen in 21% of nonresponders and in 39% of relapsers who were treated with interferon alpha-2b and ribavirin, compared with 5% of nonresponders (P = 0.001) and 9% of relapsers treated with interferon alpha-2b alone (P <0.001). At the end of follow-up, 14% of nonresponders and 30% of relapsers treated with the combination therapy had a sustained response, compared with 1% of nonresponders (P = 0.001) and 5% of relapsers treated with interferon alpha alone (P <0.001).

CONCLUSIONS

A 24-week course of treatment with interferon alpha-2b and ribavirin offers a chance of sustained response, whereas retreatment with interferon alpha-2b alone does not give satisfactory results. The role of long-term therapy in inducing prolonged remission remains to be explored.

Natural beta interferon in acute type-C hepatitis patients: a randomized controlled trial

AIM OF THE STUDY

A multicentre randomized controlled trial to assess whether a short course of beta-interferon could reduce the rate of chronic evolution of acute hepatitis C, in line with recent observations, was started in Northern Italy in 1991.

METHODS

Forty acute hepatitis C patients were randomized to receive natural beta interferon 3,000,000 international units intramuscularly three times a week for 4 weeks or symptomatic drugs, and were followed up for a median period of 22.5 months.

RESULTS

The chronicity rate was 75% (15/20 patients) in the interferon-treated group, and 80% (16/20) in the untreated group. No difference in the duration of the acute phase of hepatitis was observed. Hepatitis C virus ribonucleic acid was determined in 21 cases and was positive in 19 cases at baseline and in 15/17 chronic and 1/4 non chronic cases at the end of follow-up. Side effects of therapy (flu-like syndrome in 40% of cases) were mild and short-lasting. No aminotransferase flare-ups were observed during treatment.

CONCLUSIONS

Beta interferon at the suggested regimen is well tolerated but does not seem to significantly influence the natural course of acute hepatitis C.

Severe and complicated Falciparum malaria in Italian travelers

Imported malaria has been an important public health problem in Western countries in the last 20 years, since international travel has become an increasing habit for nonimmune populations and since chemoresistance to most antimalarial drugs has been spreading throughout the world. Moreover, immigration from African and Asian countries has been rapidly increasing, especially in Italy in the last few years. Malaria had been widespread in Italy in the past, but no new autochthonous cases have been reported since 1961. Nonetheless the number of reported cases throughout the country has been steadily growing because of imported malaria1-3 in nonimmune travelers as well as in immigrants from tropical countries. In our experience as well as according to other statistics, the vast majority of patients have Plasmodium falciparum malaria acquired in Africa.4,5 The clinical spectrum of this disease is wide, and severe cases are frequently observed, including a few fatal cases, which, although rare, are highlighted by mass media and impress the public opinion.5-8 The purpose of this study was to examine the clinical spectrum of malaria, with particular interest in severe falciparum malaria, and to define the frequency of this phenomenon and epidemiologic characteristics of patients who experience it as a life-threatening disease.

A new hepatitis C virus-like flavivirus in patients with cryptogenic liver disease associated with elevated GGT and alkaline phosphatase serum levels

The intriguing co-infection of two flaviviruses (GBV-A and GBV-B) in tamarins and the recent discovery of another flavivirus (GBV-C/HGV) in humans raises the question of the relations between hepatitis C virus (HCV) and GBV-C/HGV. To address this issue the sera of 285 patients with liver disease (102 patients with cryptogenic and 183 with known forms of chronic liver disease) and 19 patients without liver disease were tested for HGV-RNA. GBV-C/HGV-RNA was detected by RT-PCR using primers encompassing 5'NC and NS5 regions and hybridization with specific biotinilated and radiolabelled probes. GBV-C/HGV RNA was found in 11 of 20 (55%) acute hepatitis C patients, in 13 of 117 (11.1%) patients with chronic hepatitis C, in 11 of 27 patients with a liver transplant (40.7%), one of 19 (5.3%) patients with chronic HBV infection, 15 out of 102 (14.7%) patients with cryptogenic liver disease and two out of 19 patients with inflammatory bowel disease. In cryptogenic patients, elevated serum gammaglutamyl transpeptidase (GGT, higher than twice the normal values) and alkaline phosphatase (ALP, above normal values) levels were significantly associated with GBV-C/HGV-RNA infection (P < 0.001). In conclusion GBV-C/HGV appears to be transmitted in humans by blood exposure and to be associated with liver disease in HCV co-infected patients and in a minority of patients with cryptogenic disease. The virus is only occasionally pathogenic for the liver and when liver damage is present; the association with the combined elevation of GGT and APH serum levels might represent a specific feature of the liver tropism of the agent.

[Multiple cutaneous leishmaniasis after a stay in Central America]

Leishmaniasis is a protozoal disease affecting at least 12 millions persons, with 400,000 new cases per year. It is transmitted by a small insect, the phlebotomine sand fly. Clinical syndromes include visceral leishmaniasis and various cutaneous affections. We describe here the case of a patient affected by a multiple lesions New World cutaneous leishmaniasis, after staying in Costa Rica for tourism; we discuss the differential diagnosis and make a short summary of the principles of treatment.

[Interferon alpha treatment in chronic hepatitis C]

Alpha Interferon showed effective in the treatment of chronic type C hepatitis, but a consensus has not been reached about the selection of patients and therapy schedules so far. We treated 36 patients with chronic type C hepatitis in the outpatient ward of the 1st Infectious Diseases Dept., "Amedeo di Savoia" Hospital, Torino (Head of Dept.: Prof. W. Grillone) in the period 1990-1992. Alpha IFN 1-6 MU thrice weekly for 6-12 months was used. The average follow up period after therapy was 8.5 months. Four patients dropped out during the treatment period. The clinical response was evaluated using serum transaminases: 9 patients showed a full response, 9 patients had a hepatitis relapse after stopping the treatment, 6 patients had a partial response, and 9 were treatment failures. A better response was observed in young patients, drug addicts, with chronic persistent hepatitis and high transaminases levels. Side effects of the treatment were very frequent, but usually short lasting, and seldom responsible for dropping out.

[Splenic abscess in typhoid fever]

We report the case of a young patient with typhoid fever who complained of pain in his left hypochondrium and shoulder and recrudescence of fever after 21 days of treatment with tiamphenicol and ampicilline. Ultrasonography lead to the diagnosis of splenic abscess; the patient was splenectomized and S. typhi was cultured from the pus. Splenic abscess was frequently observed before 1940; since then only 6 more cases are reported in literature.

[Hospital costs of patients with AIDS]

We carried out a retrospective research into the hospital care cost of 52 AIDS cases we observed in our department, in the period 1984-1988. These patients required an average of 3.2 hospital admissions per year, and 101.3 hospitalization days per year, spending more than one fourth of their life span after their diagnosis of AIDS, in a hospital. The total care cost was Lit. 1,133,614,000, mostly due to the hospital stay (65.0%), but the introduction of expensive drugs will increase the cost of treatment. The average daily cost per patient was Lit. 227,900. Prognosis and cost vary according to the kind of opportunistic infection or neoplasm. The prolongation of hospitalization in consequence of social and economic problems is very frequent. A better accessibility of diagnostic systems, and a development of day-hospital and social services could reduce AIDS patients costs.

[Microscopic diagnosis of Pneumocystis carinii. Comparison of various staining technics]

The toluidine blue 0 and methenamine-silver nitrate staining techniques allowed a good microscopic distinction of Pneumocystis carinii cysts in lung autoptic impression smears. Poor results we observed with methylene blue and modified Gram techniques. With Giemsa's stain the intracystic bodies are shown, however the microscopic examination requires experience and patience.

Dose and serum concentration relationships in cimetidine-associated mental confusion

A patient with severe liver disease and mildly obnormal but stable renal function was given cimetidine on two occasions for gastrointestinal hemorrhage. In each course, dosing was initiated at half the recommended dosage of 600 mg daily, and mental status deteriorated shortly after dosing began. A further dosage decrease to 300 mg daily allowed continuation of cimetidine therapy in absence of mental status alterations. In this patient, mental status changes occurred at lower serum concentrations than we have previously reported. This discrepancy was explained by analysis of cimetidine CSF concentrations, as this patient had abnormally high cimetidine blood to CSF permeability. Although the cause of increased CSF concentrations is unclear, cimetidine-associated mental confusion was dose related and completely reversible upon a decrease in dosage. Patients who develop cimetidine-associated mental status changes and who cannot have treatment stopped may be safely treated by individualizing the dosing rate.

Pharmacokinetic and clinical studies in patients with cimetidine-associated mental confusion

15 cases of cimetidine-associated mental confusion have been reported. In order that this syndrome might be investigated changes in mental status (M.S.) were correlated with serum concentrations and renal and hepatic function in 36 patients, 30 patients had no M.S. change on cimetidine and 6 had moderate to severe changes. These 6 patients had both renal and liver dysfunction (P less than 0.05), as well as cimetidine trough-concentrations of more than 1.25 microgram/ml (P less than 0.05). The severity of M.S. changes increased as trough-concentrations rose, 5 patients had lumbar puncture. The cerebrospinal fluid: serum ratio of cimetidine concentrations was 0.24:1 and indicates that cimetidine passes the blood-brain barrier; it also raises the possibility that M.S. changes are due to blockade of histamine H2-receptors in the central nervous system. Patients likely to have both raised trough-concentrations and mental confusion are those with both severe renal and hepatic dysfunction. They should be closely observed and should be given reduced doses of cimetidine.