Case report:A pediatric case of Bickerstaff brainstem encephalitis after COVID-19 vaccination and Mycoplasma pneumoniae infection: Looking for the culprit

Bickerstaff brainstem encephalitis (BBE) is a rare, immune-mediated disease characterized by the acute onset of external ophthalmoplegia, ataxia, and consciousness disturbance. It has a complex multifactorial etiology, and a preceding infectious illness is seen in the majority of cases. Immune-mediated neurological syndromes following COVID-19 vaccination have been increasingly described. Here we report the case of a child developing BBE 2 weeks after COVID-19 vaccination. Despite nerve conduction studies and CSF analysis showing normal results, BBE was diagnosed on clinical ground and immunotherapy was started early with a complete recovery. Later, diagnosis was confirmed by positive anti-GQ1b IgG in serum. Even if there was a close temporal relationship between disease onset and COVID-19 vaccination, our patient also had evidence of a recent Mycoplasma pneumoniae infection that is associated with BBE. Indeed, the similarity between bacterial glycolipids and human myelin glycolipids, including gangliosides, could lead to an aberrantly immune activation against self-antigens (i.e., molecular mimicry). We considered the recent Mycoplasma pneumoniae infection a more plausible explanation of the disease onset. Our case report suggests that suspect cases of side effects related to COVID-19 vaccines need a careful evaluation in order to rule out well-known associated factors before claiming for a causal relationship

SerpinE1 drives a cell-autonomous pathogenic signaling in Hutchinson-Gilford progeria syndrome

Hutchinson-Gilford progeria syndrome (HGPS) is a rare, fatal disease caused by Lamin A mutation, leading to altered nuclear architecture, loss of peripheral heterochromatin and deregulated gene expression. HGPS patients eventually die by coronary artery disease and cardiovascular alterations. Yet, how deregulated transcriptional networks at the cellular level impact on the systemic disease phenotype is currently unclear. A genome-wide analysis of gene expression in cultures of primary HGPS fibroblasts identified SerpinE1, also known as Plasminogen Activator Inhibitor (PAI-1), as central gene that propels a cell-autonomous pathogenic signaling from the altered nuclear lamina. Indeed, siRNA-mediated downregulation and pharmacological inhibition of SerpinE1 by TM5441 could revert key pathological features of HGPS in patient-derived fibroblasts, including re-activation of cell cycle progression, reduced DNA damage signaling, decreased expression of pro-fibrotic genes and recovery of mitochondrial defects. These effects were accompanied by the correction of nuclear abnormalities. These data point to SerpinE1 as a novel potential effector and target for therapeutic interventions in HGPS pathogenesis

Globalization effects on the reports of non-endemic parasitosis in Italy

Protozoa and helminths are responsible for several intestinal parasite infections (IPIs). Generally, helminth infections are very unsafe but scarcely reported in high-income countries, while protozoa and helminth co-infections are usually reported in children living in inadequate hygienic-sanitary conditions and in rural areas. However, the impact of growing globalization, intense travelling, international adoptions and high levels of immigrants and refugees has significantly incremented the incidence of orofecal parasitosis in non-endemic areas. Although most IPs clear without treatment when population, even children, emigrate from endemic to different geographical areas, some IPIs such as strongyloidiasis may persist for decades as subclinical infections or as low-grade disease with nonspecific clinical manifestations, unless to reappear under impairment conditions. Herein we report an unusual case of Giardia lamblia and Trichuris spp. chronic asymptomatic co-infection in a healthy adopted Romanian child, living in a Central Italy rural area, and a hidden case of Strongyloides stercoralis in an adopted Burundian child, resident in South Italy, long misdiagnosed as a recurrent undefined dermatitis. Our report suggests the need to review primary care practitioner guidelines and children’s hospital procedures for appropriate IPIs screening and follow-up, hence providing new screening and prevention strategies, in agreement with international guidelines

Defining Kawasaki disease and pediatric inflammatory multisystem syndrome-temporally associated to SARS-CoV-2 infection during SARS-CoV-2 epidemic in Italy: results from a national, multicenter survey

Background: There is mounting evidence on the existence of a Pediatric Inflammatory Multisystem Syndrome-temporally associated to SARS-CoV-2 infection (PIMS-TS), sharing similarities with Kawasaki Disease (KD). The main outcome of the study were to better characterize the clinical features and the treatment response of PIMS-TS and to explore its relationship with KD determining whether KD and PIMS are two distinct entities. Methods: The Rheumatology Study Group of the Italian Pediatric Society launched a survey to enroll patients diagnosed with KD (Kawasaki Disease Group - KDG) or KD-like (Kawacovid Group - KCG) disease between February 1st 2020, and May 31st 2020. Demographic, clinical, laboratory data, treatment information, and patients' outcome were collected in an online anonymized database (RedCAP®). Relationship between clinical presentation and SARS-CoV-2 infection was also taken into account. Moreover, clinical characteristics of KDG during SARS-CoV-2 epidemic (KDG-CoV2) were compared to Kawasaki Disease patients (KDG-Historical) seen in three different Italian tertiary pediatric hospitals (Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste; AOU Meyer, Florence; IRCCS Istituto Giannina Gaslini, Genoa) from January 1st 2000 to December 31st 2019. Chi square test or exact Fisher test and non-parametric Wilcoxon Mann-Whitney test were used to study differences between two groups. Results: One-hundred-forty-nine cases were enrolled, (96 KDG and 53 KCG). KCG children were significantly older and presented more frequently from gastrointestinal and respiratory involvement. Cardiac involvement was more common in KCG, with 60,4% of patients with myocarditis. 37,8% of patients among KCG presented hypotension/non-cardiogenic shock. Coronary artery abnormalities (CAA) were more common in the KDG. The risk of ICU admission were higher in KCG. Lymphopenia, higher CRP levels, elevated ferritin and troponin-T characterized KCG. KDG received more frequently immunoglobulins (IVIG) and acetylsalicylic acid (ASA) (81,3% vs 66%; p = 0.04 and 71,9% vs 43,4%; p = 0.001 respectively) as KCG more often received glucocorticoids (56,6% vs 14,6%; p < 0.0001). SARS-CoV-2 assay more often resulted positive in KCG than in KDG (75,5% vs 20%; p < 0.0001). Short-term follow data showed minor complications. Comparing KDG with a KD-Historical Italian cohort (598 patients), no statistical difference was found in terms of clinical manifestations and laboratory data. Conclusion: Our study suggests that SARS-CoV-2 infection might determine two distinct inflammatory diseases in children: KD and PIMS-TS. Older age at onset and clinical peculiarities like the occurrence of myocarditis characterize this multi-inflammatory syndrome. Our patients had an optimal response to treatments and a good outcome, with few complications and no deaths

Characterization of HIPK2 that, by Associating with MeCP2, Might Function as a Modifier Gene in Rett Syndrome

Mutations in the methyl CpG-binding protein 2 (MECP2) gene, located on Xq28, are responsible for almost all cases of classic RTT. Conversely, less than half of the patients with one of the variant forms of RTT carry mutations in MECP2. It seems, thus, that other genes are involved in causing RTT; moreover the fact that there are patients with milder phenotypes in spite of severe mutations argues that modifier genes might restrict the clinical outcome by regulating MeCP2 functions. To search for MeCP2 interacting proteins possibly involved in RTT we performed a yeast two-hybrid screening and identified among the positive clones HIPK2 (homeodomain interacting protein kinase 2) that belongs to a family of Ser/Thr kinases originally identified as corepressors for homeodomain transcription factors. HIPK2 has a clear role in regulating cell growth and genotoxic stress-induced apoptosis. Furthermore, its involvement in the nervous system is indicated by the neuronal defects of null mice that partially overlap those observed in Mecp2 ko mice. Since important MeCP2 functions in the nervous system are regulated by its phosphorylation we found it interesting to analyze the functional role of its interaction with HIPK2. We have thus confirmed that the two proteins associate in vitro and in vivo and phosphorylation assays have shown that MeCP2 is significantly phosphorylated by HIPK2 in vitro. Importantly, these assays have also allowed us to establish that Ser80 within the MBD of MeCP2 is a specific target of HIPK2. Functional assays have shown that ectopic MeCP2 causes an increase in cell death and an additive effect of the two proteins in inducing apoptosis in cultured cells was observed. Importantly, the role of MeCP2 in inducing apoptosis together with HIPK2 is lost when Ser80 is mutated or a kinase dead derivative of HIPK2 is used. Presently we are analyzing whether MeCP2 is a target of the kinase also in vivo and the role of the interaction for the nervous system. In favor of the hypothesis that the two proteins work in a common molecular pathway we have shown by immunohistochemistry experiments that the expression pattern of MeCP2 and HIPK2 in the brain of adult mice is highly similar. We therefore believe that these studies are relevant for understanding whether this novel MeCP2 interactor acts as a modifier gene influencing disease severity in RTT patients with mutations in MeCP2

Characterization of HIPK2 that, by Associating with MeCP2, Might Function as a Modifier Gene in Rett Syndrome.

Mutations in the methyl CpG-binding protein 2 (MECP2) gene, located on Xq28, are responsible for almost all cases of classic RTT. Conversely, less than half of the patients with one of the variant forms of RTT carry mutations in MECP2. It seems, thus, that other genes are involved in causing RTT; moreover the fact that there are patients with milder phenotypes in spite of severe mutations argues that modifier genes might restrict the clinical outcome by regulating MeCP2 functions. To search for MeCP2 interacting proteins possibly involved in RTT we performed a yeast two-hybrid screening and identified among the positive clones HIPK2 (homeodomain interacting protein kinase 2) that belongs to a family of Ser/Thr kinases originally identified as corepressors for homeodomain transcription factors. HIPK2 has a clear role in regulating cell growth and genotoxic stress-induced apoptosis. Furthermore, its involvement in the nervous system is indicated by the neuronal defects of null mice that partially overlap those observed in Mecp2 ko mice. Since important MeCP2 functions in the nervous system are regulated by its phosphorylation we found it interesting to analyze the functional role of its interaction with HIPK2. We have thus confirmed that the two proteins associate in vitro and in vivo and phosphorylation assays have shown that MeCP2 is significantly phosphorylated by HIPK2 in vitro. Importantly, these assays have also allowed us to establish that Ser80 within the MBD of MeCP2 is a specific target of HIPK2. Functional assays have shown that ectopic MeCP2 causes an increase in cell death and an additive effect of the two proteins in inducing apoptosis in cultured cells was observed. Importantly, the role of MeCP2 in inducing apoptosis together with HIPK2 is lost when Ser80 is mutated or a kinase dead derivative of HIPK2 is used. Presently we are analyzing whether MeCP2 is a target of the kinase also in vivo and the role of the interaction for the nervous system. In favor of the hypothesis that the two proteins work in a common molecular pathway we have shown by immunohistochemistry experiments that the expression pattern of MeCP2 and HIPK2 in the brain of adult mice is highly similar. We therefore believe that these studies are relevant for understanding whether this novel MeCP2 interactor acts as a modifier gene influencing disease severity in RTT patients with mutations in MeCP2

Methyl-CpG-binding protein 2 is phosphorylated by homeodomain-interacting protein kinase 2 and contributes to apoptosis

Mutations in the methyl-CpG-binding protein 2 (MeCP2) are associated with Rett syndrome and other neurological disorders. MeCP2 represses transcription mainly by recruiting various co-repressor complexes. Recently, MeCP2 phosphorylation at Ser 80, Ser 229 and Ser 421 was shown to occur in the brain and modulate MeCP2 silencing activities. However, the kinases directly responsible for this are largely unknown. Here, we identify the homeodomain-interacting protein kinase 2 (HIPK2) as a kinase that binds MeCP2 and phosphorylates it at Ser 80 in vitro and in vivo. HIPK2 modulates cell proliferation and apoptosis, and the neurological defects of Hipk2-null mice indicate its role in proper brain functions. We show that MeCP2 cooperates with HIPK2 in induction of apoptosis and that Ser 80 phosphorylation is required together with the DNA binding of MeCP2. These data are, to our knowledge, the first that describe a kinase associating with MeCP2, causing its specific phosphorylation in vivo and, furthermore, they reinforce the role of MeCP2 in regulating cell growth

Detection and prevalence of protozoan parasites in ready-to-eat packaged salads on sale in Italy

To investigate the prevalence of protozoan contamination by Giardia duodenalis, Cryptosporidium spp., Toxoplasma gondii and Cyclospora cayetanensis, in ‘ready to eat’ (RTE) salads on sale in Italy, 648 packages were purchased from industrial and local brands. Nine individual packages from each brand were collected per month, pooled and subjected to microscopy and molecular analyses. Microscopic examination of 864 slides detected Cryptosporidium spp. but also Blastocystis hominis and Dientamoeba fragilis. Molecular tools identified G. duodenalis assemblage A, Cryptosporidium parvum and Cryptosporidium ubiquitum, T. gondii Type I and C. cayetanensis. B. hominis and D. fragilis were also molecularly confirmed. The overall prevalence of each protozoan species was 0.6% for G. duodenalis, 0.8% for T. gondii, 0.9% for Cryptosporidium spp., and 1.3% for C. cayetanensis, while prevalence for B. hominis was 0.5% and for D. fragilis 0.2%. Microscopy and/or molecular tools revealed that 4.2% of the samples were contaminated by at least one protozoan species, and 0.6% of samples presented contamination by two protozoan species, with a number of oocysts ranging from 62 to 554 per g of vegetable matter for T. gondii, and 46 to 1.580 for C. cayetanensis. This is Europe's first large-scale study on the presence of protozoans in packaged salads, and shows that RTE sanitation processes do not guarantee a product free from protozoans of fecal origin