ERADICAZIONE DI INFEZIONE DA HCV DOPO TRATTAMENTO DI 8 SETTIMANE CON GRAZOPREVIR/ELBASVIR: CASE REPORT

INTRODUZIONE. Il genotipo 1b è il più comune sottotipo di HCV, responsabile del 22% delle infezioni a livello globale. La combinazione di grazoprevir ed elbasvir, assunta una volta al giorno per 12 settimane, ha dimostrato buona tollerabilità ed efficacia (>95%) nell’ottenimento della risposta virologia sostenuta a 12 settimane (SVR12), in pazienti con genotipo 1 e 4, sia naïve che treatment experienced, coinfetti HIV, senza cirrosi o con cirrosi compensata. Secondo le linee guida EASL, sulla base dei dati dello studio STREAGER, è possibile trattare i pazienti naïve con genotipo 1b e grado di fibrosi F0-F2 per 8 settimane. OBIETTIVO. Descrizione di un caso di eradicazione di infezione da HCV in paziente con grado di fibrosi F0-F1 dopo trattamento di 8 settimane con grazoprevir/elbasvir CASO CLINICO. Paziente di anni 67, giunge alla nostra attenzione per intraprendere trattamento per infezione da HCV, riferita esser nota dal 1984; in anamnesi cardiomiopatia dilatativa ipocinetica, ipertensione, angioma cavernoso epatico, litiasi colecistica multipla. Agli esami ematochimici al basale da segnalare ipergammaglobulinemia (21,1%), normale funzionalità epatica, crioglobuline negative, positività degli anticorpi antiDNA nativo, giudicata di non rilevanza clinica da parere reumatologico; test HIV negativo, pregressa HAV, negativi markers per HBV e sierologia per sifilide, HCV RNA 2.750.000 UI/ml, genotipo 1b, grado di fibrosi F0-F1 secondo Metavir. Viene intrapresa terapia con grazoprevir/elbasvir in data 19/03/19; a 4 settimane HCV RNA non rilevabile. Il paziente viene ricoverato in altro nosocomio per colecistite acuta pertanto non si presenta a ritirare l’ultima confezione di farmaco e sospende terapia in data 14/05/2019. Ad un mese dalla sospensione torna a controllo, riferendo aderenza completa nelle 8 settimane di assunzione del farmaco; esegue nella stessa data prelievo ematico, ripetuto a 8 e 12 settimane dal termine della terapia, con riscontro di ematochimica nei limiti e HCV RNA non rilevabile. In programma follow up clinico, laboratoristico ed ecografico semestrale. CONCLUSIONI. Nonostante l’interruzione precoce della terapia, 8 settimane di trattamento con grazoprevir/elbasvir hanno comunque permesso di ottenere una risposta virologica sostenuta (SVR12) in paziente con basso grado di fibrosi e multiple comorbosità nella real life, confermando i dati della letteratura recente

MENINGITE VIRALE DA HHV7. DESCRIZIONE DI UN CASO IN ADULTO IMMUNOCOMPETENTE

INTRODUZIONE: Human Herpesvirus 7 (HHV7) è un virus erpetico ubiquitario, la cui patogenicità non è ancora del tutto nota. Nella maggior parte dei casi l’infezione è asintomatica, sebbene siano descritti casi di febbre, exanthema subitum o convulsioni febbrili in età pediatrica. Nel paziente adulto, immunodepresso e non, sono riportati casi aneddotici di coinvolgimento del SNC (encefalite e mielite). OBIETTIVI: Descriviamo un caso clinico di meningite a liquor limpido con isolamento liquorale di HHV-7, in giovane adulto immunocompetente.CASO CLINICO: Maschio di 18 anni originario della Guinea, in Italia da 3 anni senza precedenti anamnestici. Giungeva alla nostra osservazione per febbre e cefalea con quadro clinico obiettivo di irritazione meningea, in assenza di deficit neurologici focali o alterazione del sensorio. Gli esami ematochimici mostravano PCR 1,09 mg/dl, emocromo con formula e funzionalità epatorenale nei limiti. Veniva eseguito prelievo di liquido cefalorachidiano che si presentava lievemente torbido; l’esame chimico-fisico evidenziava glicorrachia nella norma, iperprotidorrachia (87 mg/dl) e pleiocitosi (574 cell/mmc di cui 81,7% mononucleati). Su liquor sono risultati negativi: coltura per batteri e miceti, diagnosi molecolare (film array multiplex o PCR) per E. coli, H. influenzae, L. monocytogenes e N. meningitidis, S. pneumoniae, HSV 1-2, Cryptococcus, CMV, EBV, Toscana virus, Picornavirus, West- Nile virus, Usutu virus, HHV6, HHV8, Chikungunya virus, Adenovirus, Parechovirus. Positiva la PCR su liquor per HHV-7. Negativi inoltre test HIV, sierologia per HCV, VDRL e TPHA; il quadro sierologico per HBV era compatibile con vaccinazione pregressa. Nei limiti RX torace, ECG ed ecocardiogramma. Il paziente, sottoposto a terapia sintomatica, presentava rapido sfebbramento con regressione del quadro clinico. CONCLUSIONI. Sebbene l’isolamento di HHV7 su liquor potrebbe rappresentare un evento aspecifico, espressione di riattivazione di infezione latente, la negatività delle altre indagini microbiologiche effettuate e l’assenza di immunodeficit, rendono plausibile una correlazione eziologica del virus con la forma di meningite linfomonocitaria descritta

Predicting 2-drug antiretroviral regimen efficacy by genotypic susceptibility score: results from a cohort study

Background: HIV drug resistance has a deleterious effect on the virological outcome of antiretroviral therapy (ART). The aim of the study was to evaluate the ability of genotypic susceptibility score (GSS) to predict virological outcome following an ART switch to a 2-drug regimen in virosuppressed HIV-1 infected patients. Material and methods: From the ARCA database we selected HIV-1 infected patients virologically suppressed switching to 2-drug ART (2006-2018, time of switch=baseline), with pre-baseline resistance genotype and at least one HIV-1 RNA determination during follow up. Primary endopoint was virological failure (VF: an HIV-RNA, VL, ≥ 200 cps/mL or 2 consecutive ≥ 50 cps/mL). Survival analysis was used to investigate predictors of VF. The GSS predicted by the latest and the cumulative genotype (CGSS) was calculated using the Stanford hivdb (v.8.5) with respect to the 2-drug regimen started. CD4 changes from baseline at weeks 24, 48 and 96 were assessed using Student’s t-test for paired samples. Results: We included 773 patients: 522 (68%) were males, 186 (24%) heterosexuals, with median age of 50 years (IQR, 43-56), 10 years of HIV (5-20), 7 years of ART (4-15) and 5 (3-8) previous antiretroviral (ARV) lines. At baseline patients had been virologically suppressed for 6.4 years (2.5-14), allowing isolated blips. The median zenith VL was 4.9 log10 (4.4-5.5), CD4 cells count at nadir 222 (108-324) and at baseline 640 (477-860). Median GSS was 2 (1.5-2), with GSS <2 in 213 (28%) pts, median CGSS was 2 (1-2), with CGSS <2 in 250 (33%). The previous ARV classes used were NRTI in 770 patients (99%), NNRTI in 416 (54%), boosted PI in 639 (83%) and INSTI in 218 (28%). Current ARV regimens included: PI+3TC in 455 pts (59%), of which 3TC+ ATV unboosted or ATV/r or ATV/c in 181 (23%) and DRV/r or DRV/c in 274 (36%), DTG+3TC in 260 (34%) and DTG+RPV in 58 (7%). During a median observation time of 75 wks (IQR 37-120) the estimated probability of VF at 48 weeks was 6% (95% CI 5-7) among patients with GSS=2, 4% (3-5) among patients with GSS 1-1.99 and 11% (4-18) among those with GSS <1 (Log Rank p=0.21). According to CGSS, the estimated probability of VF at 48 weeks was 5% (95% CI 1-6) among patients with CGSS =2, 6% (4-8) among patients with CGSS 1-1.99 and 8% (3-13) among those with CGSS <1 (Log Rank p=0.006) (Fig 1). Observed median changes of CD4+ counts from baseline were +24 cells/μL (IQR -67;+132) at 24 weeks, +49 cells/μL (IQR -31;+159) at 48 weeks and +74 cells/μL (IQR -30; +197) at 96 weeks (p<0.001 for all comparisons). At multivariate analysis, adjusting for years of ART, CD4 cell count at nadir and at baseline, CGSS strata, number of previous ARV lines, only longer time since last VL>50 cps/mL was associated with lower risk of VF (+ 1 year, aHR 0.89, 95% CI 0.82-0.98; p=0.01). Conclusions: Despite an effect of CGSS, the duration of virosuppression was the only independent predictor of virological efficacy of switching to 2-drug regimens

Impact of resistance mutations on virological efficacy of DTG-based maintenance two-drug regimens: an ARCA cohort study

Background: Two-drug regimens (2DR) are largely prescribed as maintenance therapy, nowadays mainly based on DTG. While many data have been reported about PI-based 2DR, the impact of resistance mutations and duration of virological suppression on DTG-based 2DR remains to be clarified. The aim of this study was to evaluate the impact of resistance mutations on virological outcome of DTG-based 2DR maintenance ART. Material and methods: Virologically suppressed patients (pts) switching to DTG+3TC or DTG+RPV with pre-baseline (time of switch=baseline, BL) resistance genotype (at least PR/RT) were selected from the ARCA database. Primary endpoint was virological failure (VF: an HIV-RNA, VL, >200 cps/mL or 2 consecutive >50 cps/mL). The probability of VF was estimated by Kaplan-Meier analysis. Resistance to 2DR was defined as occurrence of at least Stanford HIVdb (v.8.5) low-level resistance (LLR) to at least one drug included in the current 2DR, based on cumulative genotype. CD4 changes were assessed using Student’s t- test for paired samples. A secondary analysis comparing 2DR with DTG-based 3D regimens was also performed. Results: A total of 318 2DR pts were analysed: 260 (82%) switching to DTG+3TC, 58 (18%) to DTG+RPV; 68% were males, median age was 51 (44-56) years, 12 (6-23) years of HIV infection, 5 (3-8) years of virological suppression, nadir CD4 231 (121-329), 5 (3-9) previous ARV lines, 59% previously exposed to INSTI, 11% with resistance to current 2DR. The integrase sequence was available in 14% of patients, none harbouring resistance to DTG. 20 VF were observed, of whom 4 (3/17 VF in DTG+3TC, 1/3 in DTG+RPV) in patients with at least LLR at BL (M184V+K219Q; D67N+K70R+K219Q; D67N+K70R+T215Y+219Q; E138A), in a median FU of 1.3 years (IQR 0.6-2). The 2-year estimated probability of VF was 8.7% (95% CI 4.4;13); 8.6% (4.1;13.1) in those without resistance and 9.7% (-4.4;23.8) in those with resistance (Log rank: p=ns, figure 1). No factor was significantly associated with VF at multivariate analysis, but in pts with <6 years of virological suppression, BL resistance was associated with a higher probability of VF (p=0.003). After 48 weeks, a statistically significant increase in CD4+ was detected (+56 cells/mmc, p<0.001), independently from baseline resistance. The 2-year estimated probability of VF in the reference 3DR group (n=564) was not different from that for the 2DR group: 8.8% (5.9;11.7) in the whole case file and 9.7% (6.6;12.8) in the presence of baseline resistance. Longer time of virological suppression was the only factor associated with a lower risk of VF in the 3DR dataset. Conclusions: DTG-based 2DRs show high virological efficacy, even in the context of predicted incomplete activity, at least within a short-term follow-up. A longer duration of virological suppression seems to decrease the impact of resistance on virological outcome, however further studies are warranted to confirm this hypothesis and possibly define a clinically useful threshold

Crisi comiziale generalizzata in giovane paziente proveniente dal Togo

Introduzione: La neurocisticercosi (NCC) è la più comune infezione elmintica del sistema nervoso centrale ed una delle principali cause di epilessia acquisita in paesi a risorse limitate. In Europa sono in aumento i casi di importazione. La diagnosi non è sempre agevole e la sua gestione richiede un approccio multidisciplinare. Obiettivo: Descriviamo un caso di verosimile NCC in una paziente recentemente immigrata che ha presentato crisi comiziale generalizzata. Caso clinico: paziente di 21 anni proveniente dal Togo, in Italia dal 2017, giunta a ricovero per primo episodio di crisi epilettica generalizzata. Non precedenti degni di nota. All’ingresso in Ospedale la paziente era apiretica, in buone condizioni cliniche, in assenza di deficit neurologici e segni meningei. Le indagini radiologiche (TC, RMN) hanno evidenziato la presenza di puntiformi calcificazioni in sede cortico-sottocorticale temporale biemisferica e corticale-parietale-posteriore con segni di edema vasogenico e captazione con aspetto “a anello” di dimensioni dai 4 ai 7 mm. L’EEG ha mostrato rara attività parossistica in regione frontale biemisferica. La visita oculistica non ha evidenziato anomalie. La TC total body e la RMN midollo spinale non hanno evidenziato segni di patologia o localizzazione extra-encefalica. Nella norma gli esami ematici. Tra le indagini microbiologiche: negative sierologie per Cisticerco (EITB), Echinococco, HIV, Toxoplasma, Borrelia, Ameba, CMV, VZV. L’esame coproparassitologico è risultato negativo. Nella norma l’analisi del liquor. Alla luce del quadro clinico- strumentale, applicando due diversi set di criteri diagnostici disponibili in letteratura, è stato possibile porre diagnosi di probabile NCC intraparenchimale. Data la natura calcifica delle lesioni cerebrali non è stato intrapreso trattamento antiparassitario, ma sola terapia antiepilettica (levetiracetam), in accordo con attuali raccomandazioni. La paziente è attualmente in follow-up clinico e strumentale e non ha presentato ulteriori crisi comiziali. Conclusione: Il caso descritto appare compatibile con NCC intraparenchimale con lesioni calcificate per le quali, accanto al trattamento antiepilettico, non viene suggerita terapia antiparassitaria. Indipendentemente dalla negatività delle indagini sierologiche (fino al 50% dei casi in presenza di forme inattive), la NCC deve essere considerata nella diagnosi differenziale, in soggetti provenienti da area endemica soprattutto a fronte di un quadro clinico, epidemiologico e neuroradiologico, compatibili

Decline of Prevalence of Resistance Associated Substitutions to NS3 and NS5A inhibitors at DAA-failure in Hepatitis C Virus in Italy over the years 2015 to 2018

Background: A minority of patients fail to eliminate HCV and resistance-associated substitutions (RASs) are commonly detected at failure of interferon-free DAA regimens. Material and methods: Within the Italian network VIRONET-C, the prevalence of NS3/NS5A/NS5B RASs was retrospectively evaluated in patients who failed an EASL recommended DAA-regimen in 2015-2018. NS3, NS5A and NS5B Sanger sequencing was performed using homemade protocols. The geno2pheno system was used to infer HCV-genotype/subtype and predict drug resistance. The changes in the prevalence of RASs over time were evaluated using the chi-square test for trend, predictors of RASs at failure were analysed by logistic regression. Results: We included 386 real-life HCV pts failed to recommended DAA regimens: 92% (271/294) Italians, 75% (286/384) males, median age was 56 years (IQR 52-61); 106 (28%) were treatment-experienced: 91 (86%) with IFN-based treatments, 26 (25%) with DAA-based regimens. Metavir fibrosis stage was F4 in 76% (245/322), 65% (240/369) had clinical cirrhosis. Patients with HIV and HBV coinfection were 10% (33/317) and 8% (6/72), respectively. HCV genotype (G) was G1b in 122 pts (32%), G3a 103 (27%), G1a 97 (25%), G4d 30 (8%), G2c 19 (5%), G3h 5 (1.3%), G4a 4 (1%) and 1 (0.3%) each for G3g, G4n/o/v. DAA regimens were: LDV/SOF in 115 (30%), DCV/SOF in 103 (27%), 3D in 83 (21%), EBR/GRZ in 32 (8%), VEL/SOF in 29 (7%), GLE/PIB in 18 (5%) and 2D in 6 (2%); ribavirin was administered in 123 (32%). Antiviral treatment was completed by 352 pts (91%), while 34 (9%) discontinued prematurely. The NS5A fasta-sequence was available for all pts, NS5B for 361 (94%), NS3 for 365 (95%). The prevalence of any RASs was 87%, namely 78/135 (58%) in NS3, 303/359 (85%) in NS5A, 114/286 (40%) in NS5B (Tab 1). The prevalence of any RASs significantly declined from 2015 to 2018 (100%, 13/13 vs 81%, 101/125, p=0.01): NS5A RASs from 100%, 13/13 to 76%, 76/100 (p<0.001), NS3 RASs from 88%, 7/8 to 44%, 28/63 (p=0.02), while NS5B RASs remained stable. Independent predictors of any RASs included liver cirrhosis/advanced fibrosis (AOR 3.72, CI 95% 1.51-9.17, p=0.004) and genotype (G2 vs G1a AOR 0.01, CI 95% 0.0-0.3, p<0.001; G3 vs G1a AOR 0.22, CI 95% 0.05-0.98, p<0.047; G4 vs G1a AOR 0.13, CI 95% 0.03-0.63, p<0.011), with a modest effect scored for past treatment (AOR 3.45, CI 95% 1.00-11.92, p=0.05), after adjusting for DAA regimen and year of genotype. Notably, full activity was predicted for GLE/PIB in 75.9% of cases and for at least two components of VEL/SOF/VOX in 59% of cases and no case with full-resistance to either regimen was found (Tab 2). Conclusions: Despite decreasing prevalence over the years, RASs remain a common signature at virological failure of DAA treatment, particularly in patients with the highest grade of liver fibrosis. Their distribution may vary according to genotype, so the identification of RASs after failure could play a crucial role in optimizing retreatment strategies

An explainable model of host genetic interactions linked to COVID-19 severity

We employed a multifaceted computational strategy to identify the genetic factors contributing to increased risk of severe COVID-19 infection from a Whole Exome Sequencing (WES) dataset of a cohort of 2000 Italian patients. We coupled a stratified k-fold screening, to rank variants more associated with severity, with the training of multiple supervised classifiers, to predict severity based on screened features. Feature importance analysis from tree-based models allowed us to identify 16 variants with the highest support which, together with age and gender covariates, were found to be most predictive of COVID-19 severity. When tested on a follow-up cohort, our ensemble of models predicted severity with high accuracy (ACC = 81.88%; AUCROC = 96%; MCC = 61.55%). Our model recapitulated a vast literature of emerging molecular mechanisms and genetic factors linked to COVID-19 response and extends previous landmark Genome-Wide Association Studies (GWAS). It revealed a network of interplaying genetic signatures converging on established immune system and inflammatory processes linked to viral infection response. It also identified additional processes cross-talking with immune pathways, such as GPCR signaling, which might offer additional opportunities for therapeutic intervention and patient stratification. Publicly available PheWAS datasets revealed that several variants were significantly associated with phenotypic traits such as “Respiratory or thoracic disease”, supporting their link with COVID-19 severity outcome

Association of Toll-like receptor 7 variants with life-threatening COVID-19 disease in males: findings from a nested case-control study

Background: Recently, loss-of-function variants in TLR7 were identified in two families in which COVID-19 segregates like an X-linked recessive disorder environmentally conditioned by SARS-CoV-2. We investigated whether the two families represent the tip of the iceberg of a subset of COVID-19 male patients.Methods: This is a nested case-control study in which we compared male participants with extreme phenotype selected from the Italian GEN-COVID cohort of SARS-CoV-2-infected participants (<60y, 79 severe cases versus 77 control cases). We applied the LASSO Logistic Regression analysis, considering only rare variants on young male subsets with extreme phenotype, picking up TLR7 as the most important susceptibility gene.Results: Overall, we found TLR7 deleterious variants in 2.1% of severely affected males and in none of the asymptomatic participants. The functional gene expression profile analysis demonstrated a reduction in TLR7-related gene expression in patients compared with controls demonstrating an impairment in type I and II IFN responses.Conclusion: Young males with TLR7 loss-of-function variants and severe COVID-19 represent a subset of male patients contributing to disease susceptibility in up to 2% of severe COVID-19