A Carniato's research while affiliated with Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico and other places

Background: An epidemic of Mycobacterium chimaera (M. chimaera) infections following cardiac surgery is ongoing worldwide. The outbreak was first discovered in 2011, and it has been traced to a point source contamination of the LivaNova 3T heater-cooler unit, which is used also in Italy. International data are advocated to clarify the spectrum of clinical features of the disease as well as treatment options and outcome. We report a series of M. chimaera infections diagnosed in Treviso Hospital, including the first cases notified in Italy in 2016. Case summary: Since June 2016, we diagnosed a M. chimaera infection in nine patient who had undergone cardiac valve surgery between February 2011 and November 2016. The time between cardiac surgery and developing symptoms ranged from 6 to 97 mo. Unexplained fever, psychophysical decay, weight loss, and neurological symptoms were common complaints. The median duration of symptoms was 32 wk, and the longest was almost two years. A new cardiac murmur, splenomegaly, choroidoretinitis, anaemia or lymphopenia, abnormal liver function tests and hyponatremia were common findings. All the patients presented a prosthetic valve endocarditis, frequently associated to an ascending aortic pseudoneurysm or spondylodiscitis. M. chimaera was cultured from blood, bioprosthetic tissue, pericardial abscess, vertebral tissue, and bone marrow. Mortality is high in our series, reflecting the poor outcome observed in other reports. Three patients have undergone repeat cardiac surgery. Five patients are being treated with a targeted multidrug antimycobacterial regimen. Conclusion: Patients who have undergone cardiac surgery in Italy and presenting with signs and symptoms of endocarditis must be tested for M. chimaera.

Background: Highly active antiretroviral therapy (HAART) is provided free of charge to all human immunodeficiency virus (HIV) positive residents in Italy. As fixed dose coformulations (FDCs) are often more expensive in comparison to the same drugs administered separately in a multi-tablet regimen (MTR), we considered a cost-effective strategy involving patients in the switch from their FDCs to corresponding MTRs including generic antiretrovirals. Aim: To verify if this would affect the virological and immunological response in comparison to maintaining the FDC regimens. Methods: From January 2012 to December 2013, we assessed the eligibility of all the HIV-1 positive adults on stable HAART being treated at our hospital-based outpatient clinic in Treviso, Italy. Participants who accepted to switch from their FDC regimen to the corresponding MTR joined the MTR group, while those who maintained a FDC regimen joined the FDC group. Clinical data, including changes in HAART regimens, respective reasons why and adverse effects, were recorded at baseline and at follow-up visits occurring at weeks 24, 48 and 96. All participants were assessed for virological and immunological responses at baseline and at weeks 24, 48 and 96. Results: Two hundred and forty-three eligible HIV-1 adults on HAART were enrolled: 163 (67%) accepted to switch to a MTR, joining the MTR group, while 80 (33%) maintained their FDCs, joining the FDC group. In a parallel analysis, there were no significant differences in linear trend of distribution of HIV-RNA levels between the two groups and there were no significant odds in favour of a higher level of HIV-RNA in either group at any follow-up and on the overall three strata analysis. In a before-after analysis, both FDC and MTR groups presented no significant differences in distribution of HIV-RNA levels at either weeks 48 vs 24 and weeks 96 vs 24 cross tabulations. A steady increase of mean CD4 count was observed in the MTR group only, while in the FDC group we observed a slight decrease (-23 cells per mmc) between weeks 24 and 48. Conclusion: Involving patients in the switch from their FDC regimens to the corresponding MTRs for economic reasons did not affect the effectiveness of antiretroviral therapy in terms of virological response and immunological recovery.

Peritonitis is an uncommon localization of tuberculosis in Italy; diagnosis and treatment are often difficult and delayed. Fifteen cases, followed by Infectious Diseases Department in Treviso from 2000 to 2010, are described. Mortality and long term complications were absent, in contrast with medical literature. The usefulness of steroid therapy is still uncertain. Other sites of infection were present in 60 percent of patients (pulmonary TB in 47%), urging the clinician to examine the case promptly to determine infectiousness status.

Histoplasma capsulatum variety capsulatum (Hcc) and Histoplasma capsulatum variety duboisii (Hcd) infections are endemic in sub-Saharan Africa [1]. Histoplasmosis due to Hcc is the most common endemic mycoses in patients with acquired immunodeficiency syndrome (AIDS) in the Ohio and Mississipi valleys of the United States, with up to 25% incidence before the era of highly active antiretroviral therapy (HAART) [2]. Hcc is also endemic in certain areas of South America, Africa and Asia, and cases have been reported from Europe [3]. African histoplasmosis due to Hcd has been described in west and central Africa, and rare imported cases of Hcd infection in human immunodeficiency virus (HIV) infected patients have been reported from Europe [3, 4]. We report four imported cases of progressive disseminated histoplasmosis (PDH) due to Hcc in HIV patients from West-Africa observed in our Infectious Diseases Unit.

Cryptococcus neoformans is a ubiquitous fungal pathogen which causes human disease ranging from asymptomatic colonization of the lungs, to severe pneumonia, mediastinitis, meningitis or generalized infection. Although cryptococcal infection shows notably opportunistic features, it is sometimes also found among apparently immunocompetent individuals, with an extremely adverse outcome in the case of SNC involvement. Therefore, when faced with a presumed healthy person with anamnestic, clinical, CSF and instrumental findings consistent with chronic meningitis/meningoencephalitis, we must also consider cryptococcosis as a possible cause of disease. This may be rapidly achieved by resorting to quite a simple serological test, namely cryptococcal antigen detection. We describe two cases of cryptococcal meningoencephalitis occurring among apparently immunocompetent subjects (both HIV-negative, not under corticosteroid or immunosuppressive regimen, nor undergoing chemotherapy or radiotherapy. Laboratory diagnostics revealed the existence of reasonable immunological deficit for both subjects. Unfortunately, we were unable to establish whether the alterations in question were preexisting or concomitant with fungal infection. Our patients' course was somewhat problematic, according to findings observed in broader-based studies: this could mostly be explained by the considerable diagnostic delay which often marks cryptococcal infections of immunocompetent individuals. Nevertheless, neither of these two cases were complicated by intracranial pressure increase, leading us to speculate whether this disease may occur less frequently under conditions of substantial immunological integrity.

A 35-year-old man was admitted to our department due to a perforated corneal wound caused by a bamboo cane. Aspergillus fumigatus was identified by aqueous tap; topical (amphotericin B 0.15% in saline solution, 1 eye drop/h for 2 days than 2 drops each 4 hours) and systemic therapy (itraconazole 400 mg/os × 3/day) were started. Because of relapse after about 20 days of this treatment, it was necessary to start a 2 month long systemic therapy with amphotericin B (1.5 mg/kg/day). The cornea healed completely. During the 3-year follow-up no complication appeared.

We present a case of Mycoplasma pneumoniae encephalitis treated by levofloxacin. The diagnosis was a serologic one and the magnetic resonance showed a relevant white substance alteration. The concentration of levofloxacin at CRF has been 3-4 times greater than the MIC of Mycoplasma pneumoniae reported in literature. Therefore, the levofloxacin can be a rational choice in the treatment of neurological Mycoplasma pneumoniae infections.