Fragmentation of Healthcare Services as a Possible Determinant of the Low Completion for the Tuberculosis Cascade of Prevention among Asylum Seekers: Results from a Prospective Study with Historical Comparison

Background: Effective screening for tuberculosis infection (TBI) among asylum seekers (AS) is crucial for tuberculosis (TB) elimination in low incidence countries. Methods: We assessed the proportion of completion of the screening for TBI among asylum seekers with a centralized delivery method compared to the decentralized model previously adopted in the study area (historical control). In the historical model (January 2017 to May 2018) screening of AS was performed at the arrival offering TBI testing (TST followed by IGRA among those positive), radiological investigation, treatment initiation and hospital referral, if needed, at three sites: migrant health clinic, pneumology clinic and infectious diseases department for active disease (decentralized model). In the study model (June 2018, centralized) all steps of screening were performed at a single site, at a minimum of 6 months after arrival. Multivariable Poisson regression analysis, with robust variance, was used to assess variables associated with the completion of screening for infection. Multivariable logistic regression was used to identify factors associated with the diagnosis of TB infection. Results: The intervention approach was offered to 144 AS with an overall 98.6% proportion of completion (98.7% for those with a positive TST). In the historical screening model, 1192 AS were candidates for screening, which was completed by 74.5% of those who started it (44.7% for those resulted TST positive). Major losses (55%) were detected in the TST/CXR-IGRA sequential step, followed by the execution of TST test (25%). The ratio of screening completion was significantly higher in the intervention period (aIRR 1.78, 95% CI 1.68–1.88) and for AS coming from high incidence TB countries (aIRR 1.14, 95% CI 1.04–1.25). Screening after 6 months from arrival and age were associated with TB infection (2.09, 95% CI 1.36–3.2 and 1.14, 95% CI 1.01–1.29). Conclusions: Screening for TBI can be improved by a centralized approach. Higher prevalence of TBI 6 months after arrival could reflect recent (either during travel or in Italy) acquisition of the infection.

Severe imported Plasmodium falciparum malaria in children: characteristics and useful factors in the risk stratification

BACKGROUND

Severe imported pediatric malaria is of concern in non-endemic settings. We aimed to determine the features of pediatric severe cases in order to design a model able to stratify patients at presentation.

METHODS

We conducted a retrospective cross-sectional study including all imported P. falciparum malaria infection in patients ≤14 years of age, treated from January 2008 to February 2019 in two tertiary hospitals: Brescia, Italy and Barcelona, Spain. Severe malaria was defined according to World Health Organization criteria. Mortality rate, pediatric intensive care unit (PICU) stay and blood transfusion were analysed as adverse outcomes.

RESULTS

Out of 139 children included, 30.9% were severe malaria. Twenty-seven (19.4%) were admitted to PICU, and transfusion was required in 14 cases (10.1%). Predictors for severe malaria were: young age, low hemoglobin, high white blood cells (WBC) and high C-reactive protein. Platelet <130,000/μl correlated with severe malaria (without statistical significance). A model that includes age, WBC and C-reactive protein shows a high specificity to classify patients without severe malaria (92.3%) with 70% PPV and 75% NPV.

CONCLUSIONS

A score based on patient's age, WBC and C-reactive protein easily available at emergency room can help to identify children with higher risk of adverse outcomes.

High-dose or multi-day praziquantel for imported schistosomiasis? A systematic review

BACKGROUND

Schistosomiasis affects more than 260 million people worldwide, mostly in sub-Saharan Africa, where more than 280 000 deaths per year are estimated. In the past few years, the increasing flow of migrants from endemic areas and the upward number of international travels have caused the emergence of the disease also in non-endemic areas. A single course of praziquantel (PZQ) 40 mg/kg is the first-line treatment recommended by the World Health Organization, mainly based on clinical trials conducted in endemic countries. No trials have been performed in non-endemic areas.

METHODS

We carried out a systematic review of case reports and case series published between 1956 and August 2017 on cases of chronic schistosomiasis (infection acquired >3 months before) diagnosed in non-endemic areas and treated with PZQ. Primary outcome was to assess the number of different therapeutic regimens deployed and their frequency of use, calculated as the number of reports for each regimen over the total number of included cases.

RESULTS

The final database included 99 case reports and 51 case series, for a total of 1433 patients. In 57 of the 150 records (38%) the administered treatment was different from the one recommended by the World Health Organization. The proportion of 'alternative' regimens included increased doses of PZQ (up to 80 mg/kg) and/or prolonged duration of treatment and/or doses repeated some days/weeks apart. About 50% of the records regarding Western short-term travellers reported a non-standard treatment.

CONCLUSION

This is the first complete catalogue of the published experience with PZQ outside of endemic areas in the situation where reinfection is not an issue. We found a wide heterogeneity of the therapeutic regimens reported. Multicenter clinical trials conducted in non-endemic areas and guidelines specifically addressing the treatment of imported cases of chronic schistosomiasis are needed.

Non-typhoidal Salmonella aortitis

Non-typhoidal Salmonella (NTS) spp. causes about 40% of all infective aortitis and it is characterized by high morbidity and mortality. Human infection occurs by fecal-oral transmission through ingestion of contaminated food, milk, or water (inter-human or zoonotic transmission). Approximately 5% of patients with NTS gastroenteritis develop bacteremia and the incidence of extra-intestinal focal infection in NTS bacteremia is about 40%. The organism can reach an extra-intestinal focus through blood dissemination, direct extension from the surrounding organs and direct bacterial inoculation (e.g. invasive medical procedures). Medical and surgical interventions are both needed to successfully control the infection. Here, we report a case of abdominal sub-renal aortitis caused by Salmonella enterica serovar Enteritidis in an 80-year-old man.

Disseminated Histoplasmosis as AIDS-presentation. Case Report and Comprehensive Review of Current Literature

Progressive disseminated histoplasmosis (PDH) is an AIDS-defining illness with a high lethality rate if not promptly treated. The wide range of its possible clinical manifestations represents the main barrier to diagnosis in non-endemic countries. Here we present a case of PDH with haemophagocytic syndrome in a newly diagnosed HIV patient and a comprehensive review of disseminated histoplasmosis focused on epidemiology, clinical features, diagnostic tools and treatment options in HIV-infected patients.

Imported malaria in northern Italy: epidemiology and clinical features observed over 18 years in the Teaching Hospital of Brescia

BACKGROUND

Even though malaria incidence is decreasing worldwide, travel-related cases reported in Europe have remained stable in recent years. In Italy, incidence had increased in the 1990s, reaching a peak in 1999; a slow decline was then reported over the subsequent decade. To our knowledge, few published data are available on imported malaria in Italy since 2010. In this article we aimed to analyse trends in imported malaria in the teaching hospital of Brescia, northern Italy, over the last 18 years.

METHODS

All malaria cases diagnosed from 1999 to 2016 in Spedali Civili Hospital, Brescia, were retrospectively identified. Demographic, clinical and travel-related data were described.

RESULTS

A total of 1200 cases of imported malaria were diagnosed in Brescia during the study period. Among them, 225 were children. A trend of increasing paediatric cases was identified over the study period, while cases in adults were stable. Most cases were diagnosed between August and October. Patients were most likely exposed in sub-Saharan Africa (87.2%). The main reported travel reason was travelling to visit friends and relatives (66.0%). A significantly higher risk of severe malaria was observed in non-immune patients and children visiting friend and relatives (P < 0.001 and P = 0.006, respectively).

CONCLUSIONS

Our study reveals a relatively stable incidence in imported malaria cases with a peak during the summertime. A large and increasing paediatric burden of disease was identified. Imported malaria requires attention since in Italy a potential reappearance of autochthonous Plasmodium vivax malaria transmission cannot be excluded. Preventive action and physician awareness should be especially directed to children visiting friends and relatives in endemic countries and to non-immune patients since they both represent high-risk groups for severe malaria.

Lymphoproliferative disease with mixed cryoglobulinemia and hyperviscosity syndrome in an HIV-infected patient: HCV is the only culprit

The availability of direct antiviral agents (DAAs) offers the possibility to treat HCV-infected patients with a high rate of efficacy and a good safety profile. Little is known about the benefit of DAAs on HCV-related hematological diseases and their complications. We describe the case of an HIV/HCV-infected patient with HCV-related chronic lymphoproliferative disease, mixed cryoglobulinemia and hyperviscosity syndrome. Treatment with direct antiviral agents (DAAs) cured HCV infection and its complications, while HCV re-infection caused recrudescence of the associated diseases.

Febrile rhabdomyolysis of unknown origin in refugees coming from West Africa through the Mediterranean

OBJECTIVES

Cases of undiagnosed severe febrile rhabdomyolysis in refugees coming from West Africa, mainly from Nigeria, has been observed since May 2014. The aim of this study was to describe this phenomenon.

METHODS

This was a multicentre retrospective observational study of cases of febrile rhabdomyolysis reported from May 2014 to December 2016 in 12 Italian centres.

RESULTS

A total of 48 cases were observed, mainly in young males. The mean time interval between the day of departure from Libya and symptom onset was 26.2 days. An average 8.3 further days elapsed before medical care was sought. All patients were hospitalized with fever and very intense muscle aches. Creatine phosphokinase, aspartate aminotransferase, and lactate dehydrogenase values were abnormal in all cases. The rhabdomyolysis was ascribed to an infective agent in 16 (33.3%) cases. In the remaining cases, the aetiology was undefined. Four out of seven patients tested had sickle cell trait. No alcohol abuse or drug intake was reported, apart from a single reported case of khat ingestion.

CONCLUSIONS

The long incubation period does not support a mechanical cause of rhabdomyolysis. Furthermore, viral infections such as those caused by coxsackievirus are rarely associated with such a severe clinical presentation. It is hypothesized that other predisposing conditions like genetic factors, unknown infections, or unreported non-conventional remedies may be involved. Targeted surveillance of rhabdomyolysis cases is warranted.

Louse-borne relapsing fever in a refugee from Mali

INTRODUCTION

Due to the increasing number of refugees from East Africa, louse-borne relapsing fever (LBRF) has become an emergent disease in Europe. No single case of LBRF has been reported in Europe in refugees from other parts of Africa.

CASE REPORT

We report a case of LBRF in a refugee from Mali, likely acquired in Libya, where several migration routes into Europe meet. The disease must be considered in any febrile refugee regardless the country of origin.

Colitis during new direct-acting antiviral agents (DAAs) therapy with sofosbuvir, simeprevir and ribavirin for genotype 1b hepatitis C

Since 2014 several direct-acting antivirals (DAAs) have been made available, allowing interferon-free antiviral treatments with high sustained virological response rates. Side effects are, however, a real challenge during treatment. Sarkar et al. recently published a case of colitis following initiation of sofosbuvir and simeprevir for genotype 1 hepatitis C. We report the case of a patient with no prior history of inflammatory bowel disease, who developed significant bloody diarrhea within 3 weeks of sofosbuvir/simeprevir/ribavirin initiation. Colonoscopy and biopsy suggested a drug-induced colitis.

Chlamydia trachomatis genotypes in school adolescents, Italy

Chlamydia trachomatis genogroups using ompA and multilocus sequence typing (MLST) were determined in consecutive isolates from school students aged 18 or older in the district of Brescia, Italy, 2012-2013. Among 40 samples, 4 ompA genovars and 18 STs were identified. Genovar E predominated (70 %) including five STs derived from ST59 (29 % of all isolates). This study, combining ompA and MLST typing of C. trachomatis school teenagers, suggests limited mixing and sexual interchange in this population.

Gastrointestinal symptoms in atopic eczema

AIMS

To determine the prevalence of gastrointestinal symptoms in children with eczema and the association of such symptoms with the extent of eczema or skin prick test results.

METHODS

Sixty five children with atopic eczema and a control group matched for age and sex were recruited. Their parents completed a questionnaire about the children's gastrointestinal symptoms. The children's skin was examined; their weight, height, and abdominal circumference were measured; and skin prick tests were carried out.

RESULTS

Gastrointestinal symptoms, especially diarrhea, vomiting, and regurgitation, were more common in the children with eczema. Diarrhea appeared to be associated with the ingestion of specific foods. Gastrointestinal symptoms were related to diffuse eczema and positive skin prick tests to foods. There was no anthropometric differences between the patient and control groups.

CONCLUSIONS

A gastrointestinal disorder is common in children with eczema, especially with diffuse distribution. This may be responsible for substantial symptoms and may play a part in the pathogenesis of the disease and in the failure to thrive with which it is sometimes associated.

Overnight growth hormone secretion in short children: independence of the sleep pattern

PURPOSE

to analyze the interrelationships between GH secretion and pattern of sleep.

PATIENTS

18 children (10 male, 8 female; mean age 9.1 yr, range 5.1-14.3 yr), with short stature (mean height standard deviation score (SDS) -2.52, range -3.86-(-)1.88; mean height velocity SDS -1.1, range -2.40-(-)0.08), including 9 children with genetic short stature and 9 with idiopathic short stature.

METHODS

blood samples were taken every 15 min from 2000 h-0800 h, and GH profiles were analyzed by the PULSAR computerized peak identification algorithm; simultaneous sleep was analyzed by electroencephalogram recording.

RESULTS

no significant correlation was noted between GH secretion parameters and any of the electroencephalogram parameters evaluated: stage 1 (S1) percent, stage 2 (S2) percent, slow-wave sleep (SWS) percent, rapid eye movement sleep percent, wakefulness (W) percent, and sleep efficiency (EFF); there was no significant difference in GH secretion between children with EFF less than 76% and those with EFF more than 76% (P > 0.5). Maximal GH peak coincided 9 times (50%) with SWS, 3 times (17%) with S2, 3 times with W, twice (11%) with S1, and once (6%) with rapid eye movement sleep. First GH peak coincided 12 times (67%) with W, 3 times with S2, twice with SWS, and once with S1. There was no significant difference comparing the percentage of sleep stages occurring in the 15 min of maximal GH increment, in the 15 min preceding it, and in those following it; there was no significant difference comparing the percentage of sleep stages occurring in the 15 min preceding the onset of a GH peak and in those following it.

CONCLUSIONS

GH secretion in short children seems independent of the sleep stage and efficiency; in children it is possible that GH secretion relates with sleep per se and with neurohormonal changes occurring at nighttime rather than with a specific sleep stage or sleep stage sequence.