CD69 expression on Treg cells prevents chronic heart damage after myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministerio de Ciencia e Innovación (MCIN), through the Carlos III Institute of Health (ISCIII)-Fondo de Investigación Sanitaria (PI19/00545)

Background

Increasing evidences advocate for an important function of T cells in controlling immune homeostasis and pathogenesis after myocardial infarction (MI), although the molecular mechanisms remain elusive.

Result and Methods

In this study, a broad analysis of immune markers in 283 patients show a significant CD69 overexpression on Treg cells after MI. Our results in mice demonstrate that CD69 expression on Treg cells increases survival after left-anterior-descending coronary artery (LAD)-ligation. Cd69-/- mice develop strong IL17A+ gdT cell responses after ischemia that increase myocardial inflammation and, consequently, worsen cardiac function. CD69+ Treg cells induce apoptosis and decrease IL-17A production in gdT cells by a CD39-dependent mechanism. Adoptive transfer of CD69+ Treg cells to Cd69-/- mice after LAD-ligation reduces IL17A+ gdT cell recruitment increasing survival. Consistently, clinical data from two independent cohorts of patients indicate that increased CD69 expression in peripheral blood cells after acute MI is associated with a lower risk of re-hospitalization for chronic heart failure (CHF) after 2.5 years of follow-up. This result remained significant after adjustment for age, sex and traditional cardiac damage biomarkers (OR 0.929, 95% CI, 0.838-0.980; p<0.0409).

Conclusion

Our data highlight CD69 expression on T cells as a therapeutic and prognostic target to prevent CHF after MI.

Influence of treatment modality and neointimal characteristics on optical coherence tomography on clinical outcomes of in-stent restenosis

Background

In-stent restenosis (ISR) represents the more frequent modality of stent failure. The currently recommended treatment strategies are represented by repeat drug-eluting stent (DES) implantation or drug-coated balloon (DCB) angioplasty. Optical coherence tomography can display important information regarding mechanisms of stent failure as well as neointimal characterization.

Purpose

Aim of the present study was to determine the impact of treatment modality (DES vs. DCB) as well as neointimal characteristics (homogeneous vs. non-homogeneous) as determined by intravascular OCT, on clinical outcomes and explore whether there is an interaction between neointimal pattern of ISR and treatment modality.

Methods

Patients presenting with ischemic symptoms and/or evidence of myocardial ischemia in three European centers and undergoing intravascular OCT prior to percutaneous coronary intervention (PCI) for ISR, were retrospectively included in this study. Characterization of neointimal tissue was performed at the frame displaying the maximal %AS as well as the 5 preceding and following analyzed frames. Each frame was subdivided in 4 quadrants (90°) and the neointimal characteristics separately characterized for each of them. Based on its optical characteristics, neointimal tissue was categorized as homogeneous, heterogeneous, layered or neoatherosclerosis.

Based on the dominant neointimal type, the study population was divided in two groups, (predominantly homogeneous and non-homogeneous). Primary endpoints of the study were represented by major adverse cardiac events (MACE) and its idividual components (death, cardiac death, myocardial infarction and target lesion revascularization (TLR)) at 2 years follow-up.

Results

A total of 197 patients undergoing OCT prior to PCI for ISR were included in this study. 100 patients were classified as having predominantly homogeneous and 97 as having predominantly non-homogeneous neointima.

No association was found between predominant OCT pattern (homogenous vs. non-homogenous) and MACE at 2 years follow-up (HR=1.01, 95% CI: 0.59–1.75; p=0.94), or the individual MACE components. Analogously, no significant differences in terms of MACE at 2 years were found between predominantly homogeneous vs. non-homogeneous neointima in the patient subgroup receiving a DES (p=0.10) and in that undergoing DCB treatment (p=0.11).

However, a significant interaction was found between neointimal tissue pattern and treatment modality in terms of MACE (p=0.02) aa well as death or MI (p=0.016). Predominantly non-homogeneous neointima in patients treated with DCB was associated with a higher incidence of MACE.

Conclusions

Our results indicate that there is a significant interaction between treatment modality of ISR (DES vs. DCB) and neointimal pattern as determined by intravascular OCT. These results land initial support to an OCT-guided treatment of ISR and should be confirmed by larger trials.

Funding Acknowledgement

Type of funding source: None

P5630Morphometric and qualitative differences in neointimal tissue six months after implantation of bioresorbable scaffolds versus conventional everolimus eluting stents in ISAR-Absorb MI trial

Background

Bioresorbable scaffolds (BRS) are novel devices designed to overcome the long-term limitations of permanent metallic stent implantation. Optical coherence tomography (OCT) surveillance can provide important insights on the process of vessel wall healing at follow-up.

Purpose

We sought to compare OCT-assessed healing at 6 months after implantation of everolimus-eluting BRS and everolimus-eluting metallic stents (EES) in patients treated for acute myocardial infarction (AMI).

Methods

ISAR-Absorb MI is a multicentre, 2:1 randomized trial comparing outcomes of patients with AMI stented with BRS or conventional EES. Angiographic surveillance was planned for all patients at 6–8 months follow-up. Patients who had OCT surveillance at follow-up were included for the present analysis. Analysis of contiguous OCT cross-sections- 1 mm apart was performed at a centralized core laboratory. Tissue characterisation using a 256-level grey-scale signal intensity (GSI) analysis was also performed for all neointimal regions of interest (ROI) with thickness of 100 to 400 μm. ROI's were classified as mature using a standard cut-off GSI score of 109.7. Generalised linear mixed model (GLMM) was used as appropriate. Statistical analysis was performed using R software. Data is presented as numbers, percentages or median (Interquartile range, IQR).

Results

Median follow-up interval was 216 days. 70 patients in the BRS arm and 33 patients in the EES arm were available for analysis. Stented length was 19.8 mm (13.6, 24.5) and 22.3 mm (16.7, 26.4) in BRS and EES arms respectively (p=0.73). Minimum lumen area [5.13 (3.95, 6.71) vs. 4.83 (3.63, 6.92) mm2] and minimum stent area [5.78 (4.88, 7.34) vs. 6.36 (4.70, 7.45) mm2] were comparable between BRS and EES.

2,262 frames (1,529 in BRS, 733 in EES) with 20,033 struts (12,704 in BRS, 7,329 in EES) were assessed. Overall strut coverage was better with BRS compared to EES (97.5% vs. 91.1% respectively, p<0.001). Malapposed (1.1% vs. 0.5%, p=0.54) and uncovered struts (7.3% vs. 1.3%, p<0.001) were more common with EES. Neointimal coverage was comparable amongst both stent groups [85.5 (61.9, 124.1) vs. 71.5 (33.4, 133.0) μm in BRS and EES groups respectively, p=0.50].

GSI analysis in 95 cases (65 cases, 2,233 ROIs in BRS; 30 cases, 1,210 ROIs in EES) showed that immature ROIs were numerically more common in the EES group as compared to the BRS group (75.4 vs. 57.0% respectively; p=0.35).

Two-year clinical follow-up and analysis of correlation of clinical outcomes with OCT findings will also be available for presentation at ESC Congress 2019.

Conclusions

In selected patients undergoing OCT imaging at 6–8 months after implantation of BRS and conventional EES for AMI, we observed generally favourable healing characteristics with high rates of strut coverage, low rates of strut malapposition and fewer areas of immature neointimal areas with BRS in comparison to EES.

Acknowledgement/Funding

The study was predominantly funded by Deutsches Herzzentrum München and in part by a grant from Abbott Vascular

Neoatherosclerosis causing edge in-stent restenosis: optical coherence tomography findings

A patient presenting with ‘edge’ in-stent restenosis 12 years after the implantation of a bare-metal stent in the mid-left anterior descending coronary artery is described. Optical coherence tomography disclosed the presence of ruptured neoatherosclerosis at the stent edge. The value of this imaging technique to unravel this unique underlying anatomic substrate is discussed. The therapy of choice for patients presenting with edge in-stent restenosis (ISR) is reviewed.

[Anaesthetic implications in a pregnant patient with an extreme thrombocytopenia due to a May-Hegglin anomaly: general o regional anaesthesia?]

The May-Hegglin anomaly is an inherited disorder, so uncommon that the incidence is still unknown. It is characterized by macro-thrombocytopenia with normal platelet function and cytoplasmic inclusion bodies in granulocytes. The case is reported of a 28-year-old primiparous patient who had an urgent caesarean section due to failed induction of labour. The patient had no history of abnormal bleeding. Other causes of thrombocytopenia or platelet dysfunction, such as preeclampsia, HELLP syndrome, or placental abruption, were ruled out. The platelet count prior to surgery was 20,900/mm(3) with normal platelet function. General anaesthesia was performed. No excessive bleeding occurred and a platelet transfusion was not needed.

[Do women from Seine-Saint-Denis have different prenatal care compared to other women in the region?]

OBJECTIVE

We compared the care of pregnant women residing in Seine-Saint-Denis (SSD) to those resident elsewhere in Île-de-France because of the high rate of perinatal and infant mortality in this district.

MATERIALS AND METHODS

Data come from the French national perinatal surveys of 2003 and 2010 (n=969 in Seine-Saint-Denis, n=5636 other Île-de-France). We analyzed two indicators: inadequate prenatal care (late initiation, <3 ultrasounds, insufficient number of visits) and lack of knowledge of about screening and diagnostic tests for Down's Syndrome. Models were adjusted for sociodemographic characteristics.

RESULTS

Nineteen percent of women in Seine-Saint-Denis and 12 % elsewhere in Île-de-France had inadequate care and 29 % and 16 % did not know if they had been screened for Down's Syndrome. These rates were higher among migrant women but did not differ by place of residence (25 and 40 % respectively). For French citizens, residence in Seine-Saint-Denis was a risk factor for both indicators.

CONCLUSION

A reflection on how to improve care during pregnancy should be initiated in Seine-Saint-Denis.

Reducing Eurasian wild boar (Sus scrofa) population density as a measure for bovine tuberculosis control: effects in wild boar and a sympatric fallow deer (Dama dama) population in Central Spain

Research on management of bovine tuberculosis (bTB) in wildlife reservoir hosts is crucial for the implementation of effective disease control measures and the generation of practical bTB management recommendations. Among the management methods carried out on wild species to reduce bTB prevalence, the control of population density has been frequently used, with hunting pressure a practical strategy to reduce bTB prevalence. However, despite the number of articles about population density control in different bTB wildlife reservoirs, there is little information regarding the application of such measures on the Eurasian wild boar (Sus scrofa), which is considered the main bTB wildlife reservoir within Mediterranean ecosystems. This study shows the effects of a management measure leading to a radical decrease in wild boar population density at a large hunting estate in Central Spain, in order to assess the evolution of bTB prevalence in both the wild boar population and the sympatric fallow deer population. The evolution of bTB prevalence was monitored in populations of the two wild ungulate species over a 5-year study period (2007-2012). The results showed that bTB prevalence decreased in fallow deer, corresponding to an important reduction in the wild boar population. However, this decrease was not homogeneous: in the last season of study there was an increase in bTB-infected male animals. Moreover, bTB prevalence remained high in the remnant wild boar population.

[Neonatal mortality in Seine-Saint-Denis: analysis of neonatal death certificates]

The neonatal mortality rate in Seine-Saint-Denis in 2008 was 3.7 per 1000 live births vs. 2.6 in Île de France and 2.4 in Metropolitan France. The analysis of neonatal death certificates between 2001 and 2008 did not find any specific difference in the causes or characteristics of these deaths when compared with Ile de France or Metropolitan France. It seems that excess mortality in SSD affects all deaths, regardless of their cause.

Kounis syndrome secondary to amoxicillin use in an asthmatic patient

A sixty-four year old man with a past history of hypercholesterolemia, asthma, food allergy, epilepsy and myocardial infarction was admitted to the emergency department because of a generalized erythema, nausea, vomiting, and chest pain after taking an oral dose of amoxicillin. Electrocardiography showed ST segment elevation in anterior leads. After coronary angiography, type 2 variant of Kounis syndrome was diagnosed. We present the first case of oral amoxicillin induced Kounis syndrome in an asthmatic patient with severe anaphylactic shock. The present report also shows that atopic people expressing an amplified mast cell degranulation may have more serious hemodynamic decompensation during hypersensitivity reactions. Case selective mast cell surface membrane stabilization should be considered a potential therapeutic strategy for people with food induced allergy, for atopic patients and for patients who have already experienced a first Kounis syndrome.

Splenic marginal zone lymphoma--a clinicopathological study in a series of 16 patients

Splenic marginal zone lymphoma (SMZL), characterized in the WHO classification of lymphoid tumors, is a rare disorder comprising less than 1% of lymphoid neoplasms; only a few series concerning this entity have been published. Although this type of lymphoma is well defined histologically, its histogenesis remains obscure. Moreover, specific biological markers are still lacking and immunophenotype profile is not specific. These and other reasons, such as the existence of cytogenetic subtypes, have led to some authors to suspect that SMZL constitutes a heterogeneous entity. We have analyzed a series of sixteen SMZL cases from four hospitals in our community, from a clinical, biological and pathological point of view. When compared with those reported in the literature, our findings show three main differences: our patients less frequently showed an intrasinusoidal bone marrow infiltration pattern; the presence of a serum monoclonal component was rarely seen; and CD5-positive SMZL cases appear to be more common than previously thought.

[Focal presentation of progressive multifocal leukoencephalopathy: first manifestation of human immunodeficiency virus infection]

INTRODUCTION

Progressive multifocal leukoencephalopathy (PML) is a subacute demyelinating disorder of central nervous system caused by an opportunistic papovavirus infection of oligodendroglial cells, the JC virus. This virus remains latent in the human host. Their antibodies are detectable in 70% of healthy adult subjects. It is reactivated by different diseases and medical therapies impairing cellular immunity.

CLINICAL CASE

A 35 year-old man, smoker, allergic to penicillin and derivatives, with a history of endovenous drug abuse, was admitted to Neurology Department due to a progressive left facial palsy and hand weakness. An alteration in the cellular immune ratio (CD4/CD8 0.07) and a positive human immunodeficiency virus serology were demonstrated. Highly active antiretroviral therapy (HAART) was started. A unique wide hyperintense subcortical right temporoparietal lobe lesion was shown by a cerebral magnetic resonance imaging (MRI), suggesting a differential diagnosis between PLM and low grade glial tumor. Cerebrospinal fluid study was normal and the polymerase chain reaction (PCR) was negative for JC virus. A steroataxic cerebral biopsy was made in order to establish a correct diagnosis due to patient's age and the good response to treatment. The pathology study showed changes suggestive of PLM and a positive-PCR test for JC virus.

DISCUSSION

We report this case to suggest that inva- sive diagnosis methods may be useful to differentiate between PLM and low grade glial tumors and to establish a correct prognosis. HAART is becoming a good treatment option because it seems to make long term survival longer, as is the case of this patient who is practically asymptomatic after more than 2 years of evolution.

Bronchial responsiveness to bakery-derived allergens is strongly dependent on specific skin sensitivity

BACKGROUND

Quantitative relationships between immunological reactivity, non-specific bronchial responsiveness and bronchial responsiveness to allergens have scarcely been investigated in occupational asthma.

METHODS

We assessed the above relationships in 24 subjects with baker's asthma. The skin endpoint titration to bakery allergens as a measure of immunological reactivity, together with the methacholine PC20 and allergen PC20 during early asthmatic reaction were determined.

RESULTS

All patients had positive skin tests to some bakery allergens (wheat and rye flour, soybean flour, fungal enzymes and egg white proteins) and bronchial hyperresponsiveness to methacholine. Specific inhalation challenge (SIC) tests were performed with aqueous allergen extracts of cereal flour (n = 14), soybean (n = 8), baking enzymes (n = 12), and egg white proteins (n = 8) in sensitized workers. A positive asthmatic reaction was observed in 84% of the inhalation challenges. SIC elicited isolated early asthmatic reactions in 62%, dual reactions in 32% and isolated late reactions in 5%. Multiple linear regression analysis showed allergen PC20 as a function of skin sensitivity to allergen and methacholine PC20, yielding the following highly significant regression formula: log-allergen PC20 = 0.18 + 0.99 log(skin sensitivity) + 0.343 log(methacholine PC20) (r = 0.89, P < 0.001). This formula predicted allergen PC20 to within one double concentration in 67%, to within two double concentrations in 85% and within three double concentrations in 97%.

CONCLUSION

The main determinant of bronchial responsiveness to allergen in patients with baker's asthma is the degree of sensitization to occupational allergens as determined by skin reactivity, modulated to a lesser extent by non-specific bronchial hyperresponsiveness.

[Intra-abdominal desmoid tumor]

Aggressive fibromatosis (desmoid tumor) are rare connective tissue tumors that occur sporadically or in association with familial adenomatous polyposis. The etiology is unknown and clinical findings depend on growth into neighboring structures. Biopsy is required to establish the diagnosis. The treatment of choice is surgery. We report a case with unusual localization in this form of presentation. The patient remains asymptomatic 15 months after surgery.

Immunological studies in a case of hydrochlorothiazide-induced pulmonary edema

A case of acute onset non-cardiogenic pulmonary edema induced by hydrochlorothiazide (HCT) is presented. Rapid recovery was obtained with supportive therapy. Leukopenia was evident during the acute phase, with rapid recovery parallel to the clinical improvement, suggesting pulmonary sequestration of granulocytes. Immunological studies including lymphocyte stimulation test with HCT and measurement of specific IgG and IgE to HCT elicited negative results. The pathogenesis of this type of reaction remains to be elucidated.

Anaphylaxis caused by cauliflower

BACKGROUND

Cauliflower is a vegetable belonging to the family Cruciferae, genus Brassica, var. Botrytis.

METHODS

We report the case of a 70 year-old man who suffered an acute episode consisting of oropharyngeal itching, facial and hand swelling, dyspnea and severe bronchospasm within a few minutes after eating vegetable paella containing cauliflower, green beans, red and green pepper. Due to the severity of the reaction he needed treatment in the emergency room.

RESULTS

Skin prick tests with common aeroallergens were positive to Cupressus, Platanus and grass pollen. A strong skin prick test response was obtained with cauliflower and peach lipid transfer protein. Skin prick test with rice, green beans and pepper were negative. Specific IgE determinations were positive to cabbage and cauliflower, and negative to mustard.

CONCLUSIONS

The clinical history and the results of the allergologic work-up point out to this patient having experienced an IgE-mediated anaphylactic reaction to cauliflower. To the best of our knowledge, this is the first case report of anaphylaxis due to cauliflower.

Egg white proteins as inhalant allergens associated with baker's asthma

BACKGROUND

Bakery workers may develop IgE-mediated allergy to liquid and aerosolized hen's egg proteins that are commonly used in the baking and confectionery industries.

METHODS

We studied four bakery workers who had work-related allergic respiratory symptoms upon exposure to egg aerosols. The causative role of egg proteins in their respiratory symptoms was investigated by immunologic and specific inhalation challenge (SIC) tests.

RESULTS

Skin prick tests to egg white extract and to lysozyme gave positives responses in all the subjects, to ovalbumin in two, to ovomucoid in one and to egg yolk in two subjects. They were also sensitized to wheat, rye and barley flours. Specific IgE determinations to egg white were positive in all patients, to lysozyme in two, to ovalbumin in three, to ovomucoid in two and to egg yolk in two of them. Methacholine inhalation tests revealed bronchial hyperresponsiveness in all workers (PC20 < 16 mg/ml). SICs were performed with aqueous extracts of lysozyme (n = 4), ovalbumin (n = 2) and ovomucoid (n = 1), which elicited isolated early asthmatic reactions in all subjects. Double-blind, placebo-controlled, oral challenge tests with raw egg white were positive in three subjects.

CONCLUSIONS

These bakery workers had developed IgE-mediated occupational asthma to hen's egg white proteins.

Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins

There are some contradicting data about clinical allergic cross-reactivity to cephalosporins among patients who have had a previous allergic reaction to penicillins. The purpose of this study was to assess the safety of administering cephalosporins to penicillin-allergic patients. The diagnosis of penicillin allergy was made by positive skin tests to penicillin reagents and/or provocation tests with the penicillin suspected of causing the allergic reaction. To assess the clinical tolerance to cephalosporins, 41 well-characterized penicillin allergic patients diagnosed by positive skin tests and/or provocation tests were challenged with three cephalosporins that do not share the same side chain to the penicillin that induced the reactions: cephazoline, cefuroxime and ceftriaxone. Skin prick and intradermal tests with all cephalosporins tested were negative. All penicillin-allergic patients tolerated therapeutic doses of the three cephalosporins tested (cephazoline, cefuroxime and ceftriaxone) without any ill effect. These results indicate that the risk of suffering from an allergic reaction on administering cephalosporins to penicillin-allergic patients seems to be very low, provided that cephalosporins with a different side chain to the penicillin responsible for the allergic reaction are used.

Allergy to goat and sheep cheese with good tolerance to cow cheese

BACKGROUND

We report on a patient who experienced allergic reactions after eating goat cheese and after touching goat and sheep cheese, but not after consuming cow's milk dairy products.

OBJECTIVE

To assess the allergenicity and IgE-binding capacity of the caseins from the three different species.

METHODS

Skin prick tests were carried out using whole milk and caseins from three different species (goat, sheep and cow), and whey fractions of cow's milk. Total serum IgE and specific IgE to cow's milk proteins were measured by CAP system and specific IgE against caseins and whole milk were determined by ELISA technique. To evaluate allergenic cross-reactivity, inhibition of the IgE ELISA activity to goat's milk and goat casein was tested for the three caseins. SDS-PAGE and immunoblotting was used to determine IgE binding bands in caseins.

RESULTS

Skin tests were positive to sheep and goat's milk, sheep and goat casein, as well as to sheep and goat cheese. Total serum IgE was 66 kU/L and IgE determinations by CAP were negative. IgE ELISA against the caseins from goat and sheep was strongly positive, whereas it was negative to cow casein. ELISA inhibition assays revealed a high degree of cross-reactivity between goat casein and sheep casein. Immunoblotting showed three IgE-binding bands in goat casein at 31, 27 and 22 kDa, which may correspond to alpha-, beta- and gamma-caseins. A band at about 31 kDa was observed in sheep casein and another band at 34 kDa was recognized in cow casein.

CONCLUSION

This patient developed allergy to goat and sheep cheese with good tolerance to cow's milk. We identified goat casein as the main allergen causing sensitization in this patient as demonstrated by in vivo and in vitro tests. A high degree of cross-reactivity between goat and sheep casein was observed.

Beer-induced anaphylaxis: identification of allergens

BACKGROUND

We report on a 21-year-old atopic woman who developed urticaria, angioedema of the face, and wheezy dyspnea shortly after drinking beer and after eating a corn-made snack.

METHODS

Skin prick tests and specific IgE determinations to beer ingredients and cereal extracts were performed. Immunoblotting inhibition assays were carried out to investigate possible common allergens shared by barley and malt with corn.

RESULTS

Skin prick tests and specific IgE measurements with beer, barley, malt, wheat, corn, rye, rice, and oat flour were positive. Ten pollen-allergic patients showed negative skin tests to beer. Double-blind, placebo-controlled, oral challenge tests with sodium metabisulfite and wheat flour were negative. Immunoblotting demonstrated several IgE-binding bands at 31-56 kDa in malt and barley extracts, and a major band at 38 kDa in the beer extract. Immunoblot inhibition assays showed that malt extract was able to inhibit most of the IgE-binding bands in wheat and corn extracts, whereas corn did not produce significant inhibition to barley and malt extracts.

CONCLUSIONS

This patient developed type I hypersensitivity to barley/malt and corn. Although she also showed IgE reactivity to wheat and other cereals, no symptoms were elicited upon ingestion of these cereals, probably indicating latent sensitization to them.

[outbreak of invasive pulmonary mycosis in neutropenic hematologic patients in relation to remodelling construction work]

BACKGROUND

An increase was observed in the number of cases of invasive pulmonary mycosis in neutropenic hematologic patients coinciding with construction work being carried out in the Hospital Clínico San Carlos (Madrid, Spain). The aim of this study was to confirm the existence of an outbreak, identify the factors related and adopt adequate control measures.

METHODS

A descriptive, epidemiologic, environmental microbiologic study was performed. The incidence of cases in the study period and a control period was compared. Air samples were collected in the affected area and other areas of hospitalization not related to the construction work. The ventilation system of the Hemalotogy Isolation Unit (HIU) was also sampled. The control measures undertaken included: hermetic sealing of the construction work adjacent to hematology followed by transfer of the patients to another floor of the hospital.

RESULTS

The existence of an outbreak was confirmed (significant increase in the incidence, p = 0.017). Eleven cases and one death by massive hemoptisis were reported. The mean total fungal count and to Aspergillus spp were 120 and 35 UFC/m3, respectively in the hematologic hospitalization area adjacent to the construction work and 37 and 5 UFC/m3 in other areas (p < 0.001). Contamination was detected in the ventilation system of the HIU by A. fumigatus (125 UFC/m3 of air from the interior of the conduct).

CONCLUSIONS

An elevated number of fungal spores found in samples from the hematologic hospitalization area as well as no further new cases being reported following the transfer of the patients suggest that the outbreak was related to the adjacent construction work being carried out.

Visceral leishmaniasis with cutaneous lesions in a patient infected with human immunodeficiency virus

We report a case of visceral leishmaniasis (VL) with cutaneous lesions in a patient infected with human immunodeficiency virus (HIV). The cutaneous lesions consisted of erythematous papules on the legs. Biopsy of one lesion showed abundant Leishmania amastigotes within epithelial cells of an eccrine sweat gland in the dermis. Leishmania organisms were also found in a blood smear. Rapid and complete clearance of the cutaneous lesions was achieved after antimony therapy. Cutaneous lesions in VL are being reported increasingly frequently in patients with HIV infection and their significance remains in discussion.

[Miller-Fisher syndrome associated with toxoplasmosis]

We report on an immunocompetent patient who developed acquired toxoplasmosis and Miller-Fisher syndrome with central and peripheral neural involvement. We suggest the possible relationship between acquired toxoplasmosis and Miller-Fisher syndrome, even though we cannot exclude a mere coincidence. To our knowledge such an association has not been reported.

Respiratory cryptosporidiosis: case series and review of the literature

Five case of intestinal cryptosporidiosis with pulmonary involvement in patients with AIDS are reported. The diagnosis was based on the recognition of acid-fast oocysts in sputum or aspirated bronchial material and stool specimens. Coughing and excess secretions were present in all cases. Four patients had other associated pulmonary pathogens: two Mycobacterium tuberculosis, one Mycobacterium fortuitum and one Cytomegalovirus + Pneumocystis carinii; all of them had a previous (three cases) or simultaneous (one case) diagnosis of intestinal cryptosporidiosis, presenting with diarrhoea and vomiting. In the fifth patient Cryptosporidium was the only pulmonary pathogen found in a bronchial aspirate, and the onset of diarrhoea was 1 month after respiratory detection. Fifty-seven cases of respiratory cryptosporidiosis have been reported since 1980. In 17 of them, no other pathogen was found. Diarrhoea was present in 77% of the patients, cough in 77%, dyspnea in 58%, expectoration in 54%, fever in 45%, thoracic pain in 33%.

Renal invasive aspergilloma: unusual infection in AIDS

Invasive aspergillosis is a devastating infection that mainly affects immunocompromised hosts. Nevertheless it is not a common infection in AIDS probably due to specific immune aspects. Even more rare in this group of patients is infection limited to the kidney without dissemination as occurred in our case reported here. He had heroin addiction, AIDS in advanced stage C3, neutropenia and received antifungal prophyllaxis as predisposing factors to aspergillosis. Despite correct therapy with Amphotericine B and drainage of one of the abscesses, he died due to antibiotic side-effects and persistence of not-drained contralateral abscess. Our experience supports the fact that we should have a high index of suspicion for fungal aetiology in kidney infection in AIDS patients with predisposing factors discussed in the text, in order to make early diagnosis and to establish prompt aggressive antifungal therapy supported by drainage of fungus collections, or even nephrectomy if required.

Clinical cross-reactivity between amoxicillin and cephadroxil in patients allergic to amoxicillin and with good tolerance of penicillin

In recent years, patients allergic to amoxicillin (AX) but with good tolerance of penicillin G (PG) have been described. It has been suggested that the epitope implicated in this type of sensitization might be located on the side-chain of the AX molecule. Thus, cross-reactivity between AX and cephadroxil (CEPH), a cephalosporin which shares an identical side-chain with AX, is suspected. This study aimed to demonstrate clinical cross-reactivity between AX and CEPH in patients allergic to AX and showing good tolerance of PG. In 76 of 576 subjects with suspected allergic reaction to PG and/or AX, the diagnosis of allergy was confirmed. All of these had specific IgE to PG, penicillin V, or AX, and/or positive skin tests to PPL (penicilloyl-polylysine), or MDM (minor determinant mixture), or PG, or AX, and/or positive challenge tests with PG and/or AX. Sixteen subjects (21%) allergic to AX (11 with positive skin test and five with positive challenge test to AX) and good tolerance of PG (all with negative parenteral challenge test) were selected. These 16 patients were subsequently challenged with CEPH (up to 500 mg). Fourteen patients tolerated CEPH, and two (12%) had an immediate allergic reaction. Our study indicates that allergy to the side-chain of aminopenicillins seems to have little clinical relevance in patients with allergic reactions to aminopenicillins but with good tolerance of PG, as 88% of patients with this clinical characteristic tolerate a cephalosporin which shares an identical side-chain. It seems that IgE from most of these patients recognizes an epitope different from the side-chain and the beta-lactam ring.

[Tracheoesophageal fistula secondary to endoscopic sclerotherapy of esophageal varices]

Over the past 15 years, endoscopic variceal sclerotherapy (EVS) has become the main therapy for patients with bleeding esophageal varices. EVS has the advantage of a low associated mortality and morbidity, but may lead to serious complications. We report a case of esophagotracheal fistula complicating sclerotherapy that resolved with nonsurgical management.