Right to Occupational Safety: Prevalence of Latent Tuberculosis Infection in Healthcare Workers. A 1-Year Retrospective Survey Carried out at Hospital of Lecce (Italy)

BACKGROUND

Prevention of latent tuberculosis infection (LTBI) in healthcare workers (HCWs) to ensure the "Right to Occupational Safety" is a special challenge globally, as HCWs have a higher risk of acquiring the infection in hospital settings because of frequent close exposure to patients suffering from tuberculosis (TB).

METHODS

Aretrospective study was performed with the aim of assessing the prevalence of LTBI related to demographical and occupational risk factors among HCWs employed in a large hospital in Italy. The study involved 1461 HCWs screened for LTBI by Mantoux tuberculin skin test (TST) and then confirmed with Interferon Gamma Release Assay (IGRA) test in case of positivity. Immunosuppressed and BGC-vaccinated workers were tested directly with IGRA.

RESULTS

LTBI was diagnosed in 4.1% of the HCWs and the prevalence resulted lower than other studies conducted in low TB incidence countries. The variables significantly linked with higher frequency of the infection were: age ≥40 years (OR = 3.14; 95% CI: 1.13-8.74; p < 0.05), length of service ≥15 years (OR = 4.11; 95% CI: 1.48-11.43; p < 0.05) and not being trained on TB prevention (OR = 3.46; 95% CI: 1.85-6.46; p < 0.05). Not trained HCWs presented a higher risk of LTBI also after adjustment for age and length of service, compared to trained HCWs.

CONCLUSIONS

screening of HCWs for LTBI should be always considered in routinely occupational surveillance in order to early diagnose the infection and prevent its progression. Safety policies in hospital settings centered on workers' training on TB prevention is crucial to minimize LTBI occurrence in HCWs.

Overview of angiogenesis and oxidative stress in cancer

Neoplasms can be considered as a group of aberrant cells that need more vascular supply to fulfill all their functions. Therefore, they promote angiogenesis through the same neovascularization pathway used physiologically. Angiogenesis is a process characterized by a heterogeneous distribution of oxygen caused by the tumor and oxidative stress; the latter being one of the most powerful stimuli of angiogenesis. As a result of altered tumor metabolism due to hypoxia, acidosis occurs. The angiogenic process and oxidative stress can be detected by measuring serum and tissue biomarkers. The study of the mechanisms underlying angiogenesis and oxidative stress could lead to the identification of new biomarkers, ameliorating the selection of patients with neoplasms and the prediction of their response to possible anti-tumor therapies. In particular, in the treatment of patients with similar clinical tumor phenotypes but different prognoses, the new biomarkers could be useful. Moreover, they may lead to a better understanding of the mechanisms underlying drug resistance. Experimental studies show that blocking the vascular supply results in antiproliferative activity in vivo in neuroendocrine tumor cells, which require a high vascular supply.

Kinetics of Humoral Immunity against SARS-CoV-2 in Healthcare Workers after the Third Dose of BNT162b2 mRNA Vaccine

Protection provided by COVID-19 vaccines is compromised due to waning immunity over time. This study aimed to assess the level of antibodies anti-S-RBD of SARS-CoV-2 in a cohort of healthcare workers before and, on average, one and four months after the third dose of the BNT162b2 vaccine. The determination of antibodies was carried out in serum samples using an electrochemiluminescence immunoassay (ECLIA). All 34 participants (10 males, 24 females, 19 participants <50 years old, 15 participants ≥50 years old) showed a significant antibody level increase after the booster dose. Subsequently, a significant decrease in the antibody concentration was observed, with a reduction of about 60% after 150 days from the booster. Six subjects were infected by SARS-CoV-2 after the booster and showed a significantly higher antibody concentration on average four months after the third dose compared to naïve ones. Male and female participants had a similar trend in the antibody decline, while older subjects, compared to the younger ones, had a slightly slower decrease, even if they developed a lower level of antibodies after the third dose. These findings support the importance of the booster dose and underline the need for surveillance programs to better understand the antibody kinetics and optimize vaccination strategies.

Antibody Response in Healthcare Workers before and after the Third Dose of Anti-SARS-CoV-2 Vaccine: A Pilot Study

The SARS-CoV-2 pandemic led to the development of various vaccines. The BNT162b2 mRNA vaccine was the first approved due to its efficacy in eliciting a humoral immunity response after the second dose. However, a decrease in the antibody concentration was observed over time. Therefore, the administration of a third dose was scheduled, primarily for frail people and workers of essential public activities. The aim of this study was to assess the level of antibodies against the spike (S) RBD of SARS-CoV-2 in healthcare workers before and after the third dose of BNT162b2 vaccine, according to sex, age, and the time interval between vaccine doses and tests. All 37 (12 males, 25 females, 19 < 50 years old, 18 ≥ 50 years old) healthcare workers recruited showed a consistent antibody titer increase after the third dose. Data analysis showed that the antibody concentration before the third dose significantly decreased as the time interval up to the test increased, and a significantly higher level was shown in young than older people. Cluster analysis revealed that young females had a higher antibody level than older females before the third dose (p < 0.05). This study indicated the benefit of the third dose of BNT162b2 vaccine and its effect on leveling up the humoral immune response.

Effects of Influenza Vaccination on the Response to BNT162b2 Messenger RNA COVID-19 Vaccine in Healthcare Workers

Background

Vaccine-induced immunity is at present the main strategy to stop the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Recent evidences suggested a protective effect of influenza vaccination against coronavirus disease 2019 (COVID-19) severity, while impact on the immune response to BNT162b2 messenger RNA (mRNA) vaccine is under investigation.

Methods

We aimed to evaluate this aspect in a cohort of 297 healthcare workers (108 males, 189 females) after seasonal influenza vaccination compared to no-flu-vaccination. VAX+ (165 individuals; 63 males and 102 females) had tetravalent influenza vaccine, and VAX- (132 individuals; 45 males and 87 females) had no flu vaccination. Anti-spike-receptor binding domain (RBD) level was tested 15 - 70 days after BNT162b2 second inoculum.

Results

Increased antibody response was observed in total VAX+ compared to VAX- (2,047.4 vs. 1,494.2 binding antibody unit (BAU)/mL, P = 0.0039), independently from gender and body mass index (BMI). Younger total individuals (< 35 years) showed significant increase of the level of binding antibodies (2,184.8 vs. 1,590.9 BAU/mL, P = 0.0038) compared to ≥ 35 years; young/old difference was lost restricting to VAX+ subgroup. Flu vaccinations appear associated to better antibody response in older individuals (P = 0.027, ≥ 35 years VAX+ vs. VAX-). A decreasing trend during time was observed for both VAX+ and VAX-, except for < 35 years VAX- individuals. Early response was higher in VAX+ compared to VAX-; however a more rapid waning was observed in VAX+ subjects.

Conclusions

Our data showed better antibody response to SARS-CoV-2 vaccine in subjects already vaccinated against seasonal influenza; this may represent one of the mechanisms underlying the cross-protective effects of influenza vaccination against heterologous infections reported in recent epidemiological studies.

Role of ABO blood system in COVID-19: Findings from a southern Italian study

BACKGROUND

COVID-19 is a worldwide infection caused by SARS-CoV-2 and infects humans by binding to the ACE2 receptor. Blood group ABO glycoproteins can influence the binding of the virus to ACE2. The role of ABO blood system in the susceptibility to infection as well as in the clinical outcome of infected patients is still controversial and needs to be clarified.

METHODS

We conducted a retrospective study of 167 patients positive for SARS-CoV-2 who underwent nasopharyngeal swab, and of a control group represented by 891 subjects negative for SARS-CoV-2, to assess the association between ABO and Rh blood system and occurrence of SARS-CoV-2 infection, clinical presentation, and outcome of disease.

RESULTS

In the cohort of patients positive for SARS-CoV-2, no statistically significant difference in the distribution of ABO blood types compared with controls was observed. Patients with blood type A had a higher risk of developing symptomatic disease (p = 0.002; odds ratio [OR = 3.592]; 95% confidence interval [CI] = 1.576-8.187) compared to patients with blood types B, AB, and O. Patients with blood types B (p = 0.021; OR = 0.293; 95%CI = 0.099-0.869) and O (p = 0.018; OR = 0.417; 95%CI = 0.199-0.871) showed a lower risk in comparison to the other groups. The clinical progression to mild/moderate and severe/critical disease and the mortality showed no association. Moreover, no relationship with Rh blood type was found.

CONCLUSIONS

Our findings support a role of ABO blood type in the development of symptomatic disease with a higher risk in subjects with blood type A and a protective effect of blood types B and O. Blood types do not seem, however, to play a role in susceptibility, progression to severe disease, and death.

Human Leukocyte Antigen-DR Isotype Expression in Monocytes and T Cells Interferon-Gamma Release Assay in Septic Patients and Correlation With Clinical Outcome

Background

Sepsis is a life-threatening dysregulated host response to infection responsible of multiple organs dysfunction (Sepsis-3 International Consensus Definition), during which clinical outcome is a balance between inflammation and immune suppression. Monocytes and lymphocytes may play an important role in immune paralysis, and their impaired functional activity can decrease overall immune system efficiency. We evaluated sepsis-induced changes in monocytes human leukocyte antigen-DR isotype (HLA-DR) expression and T cell capacity of interferon (IFN)-γ production in relation with patient’s clinical outcome.

Methods

Analysis of HLA-DR expression on blood monocytes (mHLA-DR) was performed in 55 patients with high procalcitonin (hPCT, > 0.5 ng/mL,) and suspected/confirmed sepsis, and 20 controls. HLA-DR absolute quantification and IFN-γ release assay were monitored in 16 septic patients for 4 weeks following sepsis confirmation.

Results

Cytofluorimetric analysis revealed a significant decrease of mHLA-DR percentage in septic patients with adverse outcome compared to patients with better clinical outcome (88.4% vs. 98.6% with P < 0.05), in combination with a significant decrease of absolute number of HLA-DR molecules per monocyte (P < 0.05, starting at 1 week of follow-up). Lymphocytes stimulation with phytohemagglutinin (PHA), Staphylococcus aureus (S. aureus) and Candida albicans (C. albicans) showed a severe declining of IFN-γ release related to fatal clinical outcome of patients.

Conclusions

This immunologic anergy of innate and adaptative immunity showed an early immune paralysis during sepsis which appears correlated with the impairment of clinical outcome.

Prospective Study on Incidence, Risk Factors and Outcome of Recurrent Clostridioides difficile Infections

Background: Limited and wide-ranging data are available on the recurrent Clostridioides difficile infection (rCDI) incidence rate. Methods: We performed a cohort study with the aim to assess the incidence of and risk factors for rCDI. Adult patients with a first CDI, hospitalized in 15 Italian hospitals, were prospectively included and followed-up for 30 d after the end of antimicrobial treatment for their first CDI. A case–control study was performed to identify risk factors associated with 30-day onset rCDI. Results: Three hundred nine patients with a first CDI were included in the study; 32% of the CDI episodes (99/309) were severe/complicated; complete follow-up was available for 288 patients (19 died during the first CDI episode, and 2 were lost during follow-up). At the end of the study, the crude all-cause mortality rate was 10.7% (33 deaths/309 patients). Two hundred seventy-one patients completed the follow-up; rCDI occurred in 21% of patients (56/271) with an incidence rate of 72/10,000 patient-days. Logistic regression analysis identified exposure to cephalosporin as an independent risk factor associated with rCDI (RR: 1.7; 95% CI: 1.1–2.7, p = 0.03). Conclusion: Our study confirms the relevance of rCDI in terms of morbidity and mortality and provides a reliable estimation of its incidence.

Universal Human Papillomavirus Vaccination and its Impact on the Southern Italian Region

HPV is still the most common sexually transmitted infection, leading to the onset of many disorders while causing an increase in direct and indirect health costs. High Risk (HR) HPV is the primary cause of invasive cervical cancer and contributes significantly to the development of anogenital and oropharyngeal cancers. The introduction of universal HPV vaccination has led to a significant reduction in vaccine-targeted HPV infections, cross-protective genotypes, precancerous lesions and anogenital warts. Despite the several limitations of HPV vaccination programs, including vaccine type specificity, different schedules, target age-groups and poor communication, the impact has become increasingly evident, especially in countries with high vaccine uptake. We carried out a review of the most recent literature to evaluate the effects of HPV vaccination on vaccinetargeted HPV genotypes and to assess the level of cross-protection provided against non-vaccine HPV types. Subsequently, to assess the rates of HPV infection in a southeast Italian region, we performed an epidemiological investigation on the impact of vaccination on genotypes and on the prevalence and distribution of HPV infection during the twelve-year period 2006-2017 in the Local Health Unit (LHU) of Lecce. The vaccination coverage of about 70% among girls in the LHU led to an initial reduction in vaccine-targeted HPV types and cross-protective genotypes. However, the results on this population should be interpreted cautiously because the period since the start of vaccination is too short and the coverage rate is not yet optimal to evaluate the efficacy of vaccination in lowering the prevalence of non-vaccine HR HPV types in the vaccinated cohort and in older subjects. Nevertheless, it is expected that direct effects will increase further and that herd immunity will begin to emerge as vaccination coverage increases.

Flow Cytometric Analysis of Monocytes Polarization and Reprogramming From Inflammatory to Immunosuppressive Phase During Sepsis

Sepsis outcome is determined by a balance between inflammation and immune suppression. We aimed to evaluate monocytes polarization and reprogramming during these processes. We analyzed 93 patients with procalcitonin level >0.5 ng/mL (hPCT) and suspected/confirmed sepsis, and 84 controls by analysis of CD14, CD16 and HLA-DR expression on blood monocytes using fluorescent labeled monoclonal antibodies and BD FACS CANTO II. Complete blood cell count, procalcitonin and other biochemical markers were evaluated. Intermediate monocytes CD14⁺⁺CD16⁺ increased in hPCT patients (including both positive and negative culture) compared to controls (13.6% ± 0.8 vs 6.2% ± 0.3, p<0.001), while classical monocytes CD14⁺⁺CD16^-were significantly reduced (72.5% ± 1.6 vs 82.6% ± 0.7, p<0.001). Among hPCT patients having positive microbial culture, the percentage of intermediate monocytes was significantly higher in septic compared with non-septic/localized-infection patients (17.4% vs 11.5%; p<0.05) whilst the percentage of classical monocytes was lower (68.0% vs 74.5%). Three-four days following the diagnosis of sepsis, HLA-DR expression on monocyte (mHLA-DR) was lower (94.3%) compared to controls (99.4%) (p<0.05). Septic patients with the worst clinical conditions showed higher incidence of secondary infections, longtime hospitalization and lower HLA-DR+ monocytes compared to septic patients with better clinical outcome (88.4% vs 98.6%, p=0.05). The dynamic nature of sepsis correlates with monocytes functional polarization and reprogramming from a pro-inflammatory CD14⁺⁺CD16⁺ phenotype in non-septic hPCT patients to a decrease of HLA-DR surface expression in hPCT patients with confirmed sepsis, making HLA-DR reduction a marker of immune-paralysis and sepsis outcome. Analysis of monocytes plasticity opens to new mechanisms responsible for pro/anti-inflammatory responses during sepsis, and new immunotherapies.

Soluble Fms-Like Tyrosine Kinase-1 Is A Marker of Endothelial Dysfunction During Sepsis

Background

Sepsis is currently defined as a life-threatening organ dysfunction caused by a deregulated host response to infection. There is increasing evidence that the endothelium plays a crucial and pathogenic role in sepsis. Profound alterations of the endothelium associated with sepsis include increased leucocytes adhesions, shift to a procoagulant state, vasodilatation, altered barrier function with more permeable capillaries and tissue edema. The vascular endothelial growth factor (VEGF) pathway is involved in the control of microvascular permeability and has been involved in the pathogenesis of conditions associated with endothelial barrier disruption such as sepsis. sFlt-1 is a soluble variant of the VEGF receptor (Fms-like tyrosine kinase-1, Flt-1 or VEGFR-1) able to down-regulate the effects of VEGF by decreasing its signaling. We investigated the possible involvement of sFlt-1 as biomarker of endothelial alteration during sepsis, organ dysfunction and death.

Methods

Serum levels of s-Flt1 were measured in 170 hospitalized patients (77 with sepsis, confirmed by positive blood culture), and in 18 healthy volunteers. The sequential organ failure assessment (SOFA) score was determined by using biochemical and clinical parameters. In a small number of patients (9 individuals), s-Flt1 concentration was evaluated after negativization of the blood culture.

Results

Serum level of s-Flt1 was significantly higher in septic patients than blood culture-negative patients (277.7 ± 52.7 and 133.4 ± 12.4 pg/mL, respectively, P = 0.0088), both groups of patients had significantly higher concentration of sFlt-1 than healthy individuals (78.9 ± 2.5 pg/mL). Among sepsis cases, 68% was caused by Gram-negative bacteria, 27% by Gram-positive bacteria and 8% by Candida species. Serum level of s-Flt1 showed a significant difference between Gram-negative (274.1 pg/mL) and Gram-positive (145.7 pg/mL) sepsis. SOFA score (evaluated in 20 patients with sFlt-1 >190 pg/mL) showed a positive trend of correlation with the increasing sFlt-1 level. After blood culture negativization, serum level of sFlt-1 decreased (37%).

Conclusion

Our findings confirm, in a larger population of patients with sepsis, recent evidences that sFlt-1 levels are higher in patients with complicated-sepsis that evolve to septic shock and suggest that sFlt-1 could be a useful biomarker for sepsis severity. An anti-VEGF effect mediated by sFlt-1 could be hypothesized as salvage compensatory mechanism activated in response to sepsis.

Assessment of Serum Vitamin B12 Levels and Other Metabolic Parameters in Subjects With Different Values of Bone Mineral Density

Background

Controversial experimental and clinical evidences have raised questions regarding the role of B12 and insulin-like growth factor 1 (IGF-1) on osteoblast function and bone health. In this study, we aimed to determine if the serum levels of B12, IGF-1 and procollagen type 1 N-terminal propeptide (P1NP) are associated with different degrees of bone mineral density (BMD).

Methods

A total of 287 subjects (190 women and 97 men; mean age 53 years) volunteered for evaluation of BMD and serum levels of B12, IGF-1 and P1NP; BMD at lumbar spine and proximal femur was evaluated by means of dual-energy X-ray absorption (DEXA) and expressed as T-score; serum concentrations of vitamin B12 and IGF1 were measured with a chemiluminescent immunoassay on Access II Beckman Coulter and DiaSorin Liaison XL analyzers, respectively; P1NP was assessed in 61 women and 35 men with reduced T-score on Roche Modular platform.

Results

A total of 101 subjects (66 women and 35 men) had a reduced BMD (T-score < -1) or osteoporosis with a T-score < -2.5, while 186 (124 women and 62 men) had a normal BMD. No significant difference in the B12 levels was observed between the subjects with reduced BMD (mean 265.15 pg/mL, 95% CI: 236 - 294.25) and those with normal BMD (mean 243.91, 95% CI: 225.78 - 262.03) (P = 0.1990); lower levels of IGF-1 were observed in the group with reduced BMD (mean 138.7 pg/mL, 95% CI: 126.75 - 150.83) than in that with normal BMD (mean 167.34, 95% CI: 136.49 - 198.18) (P< 0.001); serum levels of P1NP were significantly lower in 22 subjects younger than 50 years (mean 44.8 ng/mL, 95% CI: 36.4 - 53.1) vs. 74 subjects > 50 years old (mean 53.3, 95% CI: 34.3 - 72.3) (P < 0.001), and in women (mean 45.3, 95% CI: 37.6 - 52.9) vs. men (mean 62, 95% CI: 23 - 101) (P < 0.001).

Conclusion

We found no significant association between B12 levels and BMD, but significant associations of lower levels of IGF1 with reduced BMD and lower levels of P1NP with younger age and female sex were found; additional studies to further investigate the association of serum levels of B12, growth factors and biochemical turnover markers with human bone health are needed.

Epidemiological and Virological Assessment of Influenza Activity in Apulia, Italy, during the Seasons 2004–2005 and 2005–2006

This study evaluated the impact of influenza and vaccination coverage in Apulia, Italy, during the 2004–2005 and 2005–2006 seasons, using epidemiological and virological surveillance data collected through the Italian Net of Surveillance of Influenza (InfluNet) organized by the Superior Institute of Health (ISS) and the Inter-University Centre of Research on Influenza (CIRI). Vaccination coverage was calculated from the number of doses administered to individuals aged ≤ 65 years. Sentinel physicians reported weekly influenza-like illness (ILI) and acute respiratory illness (ARI) occurrences among patients. Influenza viruses were isolated and identified by cell culture on Madin-Darby Canine Kidney cells and polymerase chain reaction techniques. Vaccination coverage reached 72.7% and 77.0% during the 2004–2005 and 2005–2006 seasons, respectively. Incidence of ILI was higher during the 2004–2005 season compared with the 2005–2006 season, whereas the incidence ARI appeared to show a more constant trend. Incidence rates for ILI and ARI were higher in the 0 − 14-year age group. The increase in vaccination coverage and implementation of a network of epidemiological and virological surveillance are fundamental for the control and prevention of influenza.

Seropositivity for West Nile Virus Antibodies in Patients Affected by Myasthenia Gravis

BACKGROUND

Myasthenia gravis (MG) is an autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles. Specific auto-antibodies against acetylcholine receptor (AChR) are present in the majority of MG patients, although the main cause behind its development still remains unclear. Recently MG development following West Nile virus (WNV) infection has been described in patients without any earlier evidence of MG. It is known that infectious agents trigger immune response and occasionally initiate autoimmune disease. WNV, the causative agent of both benign illness and neuroinvasive disease, has become endemic in many countries in all continents.

METHODS

In the present study, 29 patients (15 males and 14 females, 19 - 78 years old) with confirmed diagnosis of MG and elevated levels of AChR autoantibodies were screened for the presence of serum anti-WNV antibodies and compared to a similar population affected by different autoimmune diseases. Indirect immunofluorescent antibody technique was used to evaluate the reaction of patients' sera on cells infected by WNV.

RESULTS

Positive fluorescent signals for anti-WNV IgG were obtained in 17% of MG patients, although no clinical manifestations related to WNV infection were reported. These results are in agreement with previous data and appear of great interest in the understanding of the pathogenic autoimmune mechanisms at the bases of MG development.

CONCLUSION

As already observed in other human autoimmune diseases, pathogen-triggered autoimmunity could be involved in MG by breaking immunological self-tolerance through possible mechanisms of molecular mimicry between virus proteins and AChR subunits. In predisposed individuals, WNV infection could also represent an additional risk factor to initiate MG.

Procalcitonin, C-reactive protein and serum lactate dehydrogenase in the diagnosis of bacterial sepsis, SIRS and systemic candidiasis

The aim of this study was to evaluate procalcitonin (PCT), C-reactive protein (CRP), platelet count (PLT) and serum lactate dehydrogenase (LDH) as early markers for diagnosis of SIRS, bacterial sepsis and systemic candidiasis in intensive care unit (ICU) patients. Based on blood culture results, the patients were divided into a sepsis group (70 patients), a SIRS group (42 patients) and a systemic candidiasis group (33 patients). PCT, CRP, LDH and PLT levels were measured on day 0 and on day 2 from the sepsis symptom onset. PCT levels were higher in Gram negative sepsis than those in Gram positive sepsis, although the P value between the two subgroups is not significant (P=0.095). Bacterial sepsis group had higher PCT and CRP levels compared with the systemic candidiasis group, whereas PLT and LDH levels showed similar levels in these two subgroups. The AUC for PCT (AUC: 0.892, P <0.001) was larger than for CRP (AUC: 0.738, P <0.001). The best cut-off values for PCT and CRP were 0.99 ng/mL and 76.2 mg/L, respectively. Diagnostic sensitivity and specificity for PCT were 84.3% and 81.8% whereas CRP showed a sensitivity of 77.2% and a specificity of 63.6%. However, PCT was unable to discriminate between SIRS and systemic candidiasis groups (P=0.093 N.S.). In conclusion, PCT can be used as a preliminary marker in the event of clinical suspicion of systemic candidiasis; however, low PCT levels (<0.99 ng/mL) necessarily require the use of other specific markers of candidaemia to confirm the diagnosis, due to great uniformity of PCT levels in systemic candidiasis and SIRS groups.

Geotrichum capitatum septicaemia in a haematological patient after acute myeloid leukaemia relapse: identification using MALDI-TOF mass spectrometry and review of the literature

Emerging fungal pathogens, such as Geotrichum capitatum, are often associated with poor prognosis and represent a new challenge in modern medicine. Invasive Geotrichum capitatum infection is rare and has been reported exclusively in patients who showed signs of severe immunodeficiency, particularly those affected by haematological malignancies. The optimal therapy against systemic geotricosis has not yet been identified due to limited data about its antifungal susceptibility. The use of several therapeutic strategies and the low number of cases treated does not allow identification of specific therapeutic protocols. Furthermore, in spite of antifungal therapy, mortality rates reach very high levels. We report a case of systemic Geotrichum capitatum infection in a 78-year-old male treated with salvage therapy after acute myeloid leukaemia (AML) relapse. Geotrichum capitatum was isolated from his blood culture and identified by using Vitek 2 and Maldi time-of-flight system (MALDI-TOF). The infection was unsuccessfully treated, despite in vitro susceptibility, with micafungin and liposomal amphotericin B.

Identification of HEV in symptom-free migrants and environmental samples in Italy

Hepatitis E virus (HEV) is considered an emerging pathogen in industrialized countries. The occurrence of HEV genotypes in samples of faeces from asymptomatic migrants arriving on the coasts of South Italy and environmental samples was investigated. Analyses of sequences were used to compare human and environmental genotypes. A total of 40 stool specimens, 12 samples of untreated urban sewage, 12 samples of treated urban sewage and 12 samples of surface water were analysed. Viruses were concentrated from water samples by the tangential flow ultrafiltration technique. The presence of HEV RNA was detected by nested RT-PCR. Viral isolates were sequenced and phylogenetically characterized. Two (5%) of the 40 faecal samples tested were found to be positive for HEV RNA (G1 and G3 genotypes). The virus was detected in 25% (3/12) of the untreated sewage samples and 25% (3/12) of the surface water samples: all isolates belonged to G3 genotype. None of the treated sewage samples were found to be HEV RNA positive. The virus was detected in the faeces of two asymptomatic subjects, suggesting a potential role for symptom-free HEV carriers as a human reservoir. G3 HEV strains were detected in the untreated sewage, as observed in similar studies conducted in other European countries but differing from another study conducted in Italy recently. Moreover, our results show the first case of HEV isolated from fresh surface waters.

Molecular approaches in the diagnosis of sepsis in neutropenic patients with haematological malignances

INTRODUCTION

Sepsis is a major cause of significant morbidity and mortality in neutropenic patients. Blood culture remains the gold standard in the microbiological diagnosis of bacterial or fungal bloodstream infections, but it has clear limits of rapidity and sensitivity. The objective of the study was to compare the real-time polymerase chain reaction (RT-PCR) with automated blood cultures (BC) method in detection in whole blood of pathogens in febrile neutropenic patients with hematological malignancies.

METHODS

A total of 166 consecutive febrile neutropenic patients were enrolled. Blood samples for cultures and SeptiFast testing were obtained at the onset of fever, before the implementation of empirical antibiotic therapy.

RESULTS

Forty (24.1%) samples out of the 166 blood samples tested, were positive by at least one method. Twenty-three (13.9%) samples were positive by blood culture and 38 (22.9%) by multiplex real-time PCR. The analysis of concordance evidenced a low correlation between the two methods (n = 21; 52.5%), mainly due to samples found negative by culture but positive with the Septi-Fast assay. Sensitivity, specificity, and positive and negative predictive values of RT-PCR were 91.3%, 88.1%, 55.3%, and 98.4%, respectively, compared with BC.

DISCUSSION

Multiplex real-time PCR assay improved detection of the most bacteria associated with febrile neutropenia episodes. Further studies are needed to assess the real advantages and clinical benefits that molecular biology tests can add in diagnosis of sepsis.

Immunophenotypic characterisation of peripheral blood lymphocytes in autoimmune polyglandular syndrome type 1: clinical study and review of the literature

Autoimmune endocrinopathies are characterised by an increased number of peripheral blood lymphocytes (PBL) expressing activation/ memory markers on their surface. The aim of this study was to determine whether a similar finding could be detected in a group of 11 paediatric and young adult patients suffering from autoimmune polyglandular syndrome type 1 (APS1), also called autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), as very few data have previously been reported in this field. The control group was made up of 11 sex- and age-matched healthy subjects. Fifteen lymphocyte subsets were compared, in terms of percentage and absolute number, and statistical analysis was performed by the Mann-Whitney test. Measurement of T (CD3+), B (CD19+), natural killer (NK, CD3-CD16/56+), CD4+ and CD8+ T lymphocytes showed that patients with APS1 had a higher percentage and absolute count of T lymphocytes: this was entirely due to the statistically larger CD3+CD4+ fraction. Patients with APS1 also had slightly fewer B and NK lymphocytes, but the difference was negligible. Comparison of CD4+ subpopulations bearing activation and naive/memory antigens (marked by CD69, CD25, anti-HLA-DR, CD45RA and CD45RO) showed that patients with APS1 had generally larger percentages and absolute counts of these subsets: however, only the percentage and absolute size of the CD4+CD25+ subset (p = 0.0354 and p = 0.0151, respectively), and the absolute number of the CD4+ anti-HLA-DR+ and CD4+ CD45RO+ subsets (p = 0.0193 and p = 0.0209, respectively) were significantly higher. Interestingly, patients with APS1 also had significantly fewer CD8+CD11b+ and CD3-CD8+ cells. In conclusion, PBL distribution in APS1 resembles that of other autoimmune diseases. Further studies are needed to confirm and possibly extend these data.

Organ-specific and non-organ-specific autoantibodies in children and young adults with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED)

OBJECTIVE

The aim of the study was to assess the complex of autoantibodies which can be detected in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a rare autosomal recessive disease in which the extent of autoimmunity is still unknown.

DESIGN

Antibodies (A) to parathyroid glands, adrenal cortex (AC-A), ovary and testis (steroid cell antibodies, SC-A), pancreatic islet cells (IC-A), gastric parietal cells, and non-organ-specific antigens were investigated in 11 APECED patients living in the Salento region of southern Italy. Further measurements included antibodies to cytochrome P450 (CYP) enzymes: cholesterol side-chain cleavage enzyme (CYP11A), 21-hydroxylase (CYP21) and 17alpha-hydroxylase (CYP17); and to glutamic acid decarboxylase 65-kDa isoform (GAD65), tyrosine phosphatase-like protein IA2, thyroglobulin (TG), thyroperoxidase (TPO), thyrotropin receptor, liver CYP enzymes and intrinsic factor.

METHODS

Antibodies to organs and subcellular fractions were detected by immunofluorescence. Radiobinding, immunoradiometric, and immunoblotting assays were used for the other measurements.

RESULTS

AC-A and SC-A were positive in all sera; among antibodies to adrenal CYP enzymes, only CYP21-A were present in all the patients with Addison's disease of short-medium duration (<15 years). Of three patients with Addison's disease of long duration (>15 years), two tested positive for antibodies to all three CYP enzymes, and the other for only CYP11A-A. In all sera CYP11A-A and/or CYP17-A were found. Two patients tested positive for both IC-A and GAD65-A, one for both IC-A and IA2-A, and one for GAD65-A; the fasting C-peptide assay showed no statistical difference between these four subjects and the others. All four hypothyroid patients were positive for TPO-A, while two of them were positive and two were negative for TG-A; two euthyroid subjects had positivity for TG-A. Liver-kidney microsomal antibodies reacting against the CYP2A6 were detected in two patients with autoimmune hepatitis. All but one sera contained anti-nuclear antibodies at a titre ranging between 1:20 and 1:80; however, only two patients had a connective tissue disease (Sjögren's syndrome).

CONCLUSIONS

Several autoantibodies may be detected in any APECED patient. Our data confirm that CYP21-A and TPO-A are major autoantibodies involved in APECED-associated Addison's disease and hypothyroidism respectively, while CYP11A-A and CYP17-A correlate with positivity for SC-A. Markers of islet cell autoimmunity are frequent, but prevalence and modalities of progression to overt beta-cell failure have to be clarified. Low-titre non-organ-specific autoantibodies are a feature of autoimmunity in APECED, but their role has yet to be fully explained.

Prevalence and clinical features of cryoglobulinaemia in multitransfused beta-thalassaemia patients

OBJECTIVE

The aim of the study was to determine the prevalence of cryoglobulinaemia and its clinical features among beta-thalassaemia patients.

METHODS

Eighty eight multitransfused beta-thalassaemia patients were studied. They were physically examined and asked about the presence of cryoglobulinaemia related symptoms. Hepatitis C virus (HCV) serology, HCV-RNA, HCV subtypes, viraemia, serum ferritin, liver and kidney function tests, rheumatoid factor (RF), circulating immune complexes (CIC), complement levels and autoantibodies were all evaluated. The patients were divided into four groups: HCV-RNA positive patients with and without cryoglobulinaemia (groups A and B), HCV-Ab positive/HCV-RNA negative patients (group C), HCV-Ab negative patients (group D).

RESULTS

Cryoglobulinaemia was present in 35 of 53 (66.0%) patients with chronic HCV infection. They had higher viraemia than non-cryoglobulinaemic viral carriers, but no statistical difference relating to sex or HCV subtypes was found. In comparison with the other groups, group A patients were older, had undergone transfusion therapy for a longer period, had received a higher number of transfusions, and had increased levels of RF and CIC, as well as consumption of C4; in addition, they had a higher prevalence of cirrhosis. Cutaneous lesions (purpura, Raynaud's phenomenon, nodules and leg rash), peripheral neuropathy and sicca syndrome symptoms were present only in group A. Musculoskeletal symptoms (bone pain, arthralgia and myalgia), weakness, splenomegaly, lymphadenopathy, skin ulcers and proteinuria were also commoner in group A, but the difference did not reach statistical significance, possibly because of partial overlap between cryoglobulinaemia and beta-thalassaemia syndromes.

CONCLUSION

Because of its high prevalence in multitransfused beta-thalassaemia patients, cryoglobulinaemia needs to be systematically studied and considered in the differential diagnosis of various beta-thalassaemia manifestations.