Diagnosis and management of complicated urogenital schistosomiasis: a systematic review of the literature

Bladder cancer; Hydronephrosis; Neglected tropical diseasesCàncer de bufeta; Hidronefrosi; Malalties tropicals desatesesCáncer de vejiga; Hidronefrosis; Enfermedades tropicales desatendidasBackground Currently, there are no standardized guidelines for the diagnosis or management of the complications of urogenital schistosomiasis (UGS). This systematic review of the literature aims to investigate the state of the art in reference to diagnostic approaches and the clinical management of this condition. Methods A systematic review of literature published between January 1990 and January 2021 was conducted in the MEDLINE database, scoping for articles regarding diagnostic means or therapeutic options for the complications of UGS, namely obstructive uropathy, bladder cancer, abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures. Relevant data were then extracted from the articles deemed eligible according to the inclusion criteria. Main results In total, 3052 articles were identified by the research query, of which 167 articles fulfilling inclusion criteria after title/abstract screening and full-text evaluation were included, 35% on both diagnostic and therapeutic aspects, and 51% on diagnosis and 14% on therapy. Ultrasound was the most frequently tool employed for the diagnosis of UGS complications showing a good performance. Concerning the management of hydronephrosis, the majority of available evidences came from community-based studies where universal treatment with praziquantel was used leading to decrease of prevalence of obstructive uropathy. Concerning studies on surgical procedures, laser endoureterotomy followed by stenting was mostly employed in adult patients leading to a crude cure rate of 60% (43 of 71 patients). In the case of severe hydronephrosis, surgery consisting of ureteral re-implantation showed excellent results with a crude cure rate of 98% (157 cured patients of 160 treated). Concerning bladder cancer, data on 93 patients with a clear diagnosis of UGS-related bladder were available reporting a variable and sometime combined approach based on disease stage. Available data on diagnosis and management of abortion, ectopic pregnancy, infertility, kidney failure, urolithiasis and the need for invasive procedures due to UGS are also presented. Conclusions The review produced a complete picture of the diagnostic and therapeutic options currently available for complicated UGS. These results can be useful both for guiding clinicians towards correct management and for tracing the direction of future research.Open access funding provided by Università degli Studi di Firenze within the CRUI-CARE Agreement. The authors did not receive support from any organization for the submitted work

Shortage of Albendazole and Its Consequences for Patients with Cystic Echinococcosis Treated at a Referral Center in Italy

Albendazole (ABZ) is the best drug available to treat cystic echinococcosis (CE), a neglected tropical disease. Cystic echinococcosis patients often receive a continuous course of the drug for 6-12 months. In Italy, ABZ shortages occur almost on a yearly basis. We searched clinical records at the World Health Organization Collaborating Center for the Clinical Management of CE in Pavia, Italy, to estimate the amount of ABZ prescribed to patients between January 2012 and February 2017. The cost of ABZ was estimated at €2.25 per tablet based on the current market price in Italy. Patients to whom ABZ had been prescribed were contacted to determine if they had experienced difficulties in purchasing the drug and to assess how such problems affected their treatment. Of 348 identified CE patients, 127 (36.5%) were treated with ABZ for a total of 20,576 days. This led to an estimated cost of €92,592. Seventy-five patients were available for follow-up, 42 (56%) reported difficulties in obtaining ABZ. Of these patients, four (9.5%) had to search out of their region and 10 (23.8%) had to go out of the country. A total of 27 patients (64%) had to visit more than five pharmacies to locate the drug and 10 patients (23.8%) interrupted treatment because of ABZ nonavailability. Shortages in ABZ distribution can disrupt CE treatment schedules and jeopardize patient health

Treatment of a giant hepatic echinococcal cyst with percutaneous drainage and in vivo assessment of the protoscolicidal effect of praziquantel

Therapy choices for cystic echinococcisis (CE) are stage-specific: surgical, minimally invasive, medical or observation without intervention. PAIR (percutaneous aspiration, instillation of a scolicide, and re-aspiration) has been considered the treatment of choice for uncomplicated echinococcal liver cysts. However, PAIR carries the risk of toxic cholangitis or hypernatremia and that the cyst frequently refills with bile after withdrawing the catheter. We treated a patient with a giant CE 1 liver cyst with puncture drainage (PD) under albendazole coverage. Drainage enabled us to monitor the morphology of protoscolices under praziquantel (PZQ) co-medication. Protoscolices degenerated within 5 days of PZQ 50 mg/kg/d. The cyst cavity solidified with no evidence of reactivation or secondary spread. Percutaneous treatments can replace surgery in a significant number or cases with hepatic CE. PD allows to assess microscopically the viability of protoscolices under co-medication with PZQ-albendazole and to avoid the instillation of topical scolicides

Evaluation of the Active Melioidosis Detect™ test as a point-of-care tool for the early diagnosis of melioidosis: a comparison with culture in Laos.

BACKGROUND: Melioidosis is difficult to diagnose clinically and culture of Burkholderia pseudomallei is the current, imperfect gold standard. However, a reliable point-of-care test (POCT) could enable earlier treatment and improve outcomes. METHODS: We evaluated the sensitivity and specificity of the Active Melioidosis Detect™ (AMD) rapid test as a POCT and determined how much it reduced the time to diagnosis compared with culture. RESULTS: We tested 106 whole blood, plasma and buffy coat samples, 96 urine, 28 sputum and 20 pus samples from 112 patients, of whom 26 (23.2%) were culture-positive for B. pseudomallei. AMD sensitivity and specificity were 65.4 and 87.2%, respectively, the latter related to 10 weak positive reactions on urine samples, considered likely false positives. The positive predictive value was 60.7%, negative predictive value was 89.3% and concordance rate between operators reading the test was 95.7%; time to diagnosis decreased by a median of 23 h. CONCLUSIONS: Our findings confirm that a strongly positive AMD result can reduce the time to diagnosis of melioidosis. However, the AMD currently has a disappointing overall sensitivity, especially with blood fractions, and specificity problems when testing urine samples

ADVANCING THE CLINICAL MANAGEMENT OF CYSTIC ECHINOCOCCOSIS PATIENTS: THREE YEARS OF CLINICAL AND EPIDEMIOLOGICAL RESEARCH

The thesis illustrates the results of three years of clinical research in the field of Cystic Echinococcosis (CE). During these three years my work as a PhD student has mainly focused on three different aspects of CE-related research: CE epidemiology, clinical management, and studies on CE diagnosis with particular regard to serology and new molecular tools for the diagnosis of CE. The first presented publication analyzed the state of the art on CE-related research in the Mediterranean area and showed that much was left to be done about the three topics I focused on during my PhD. The studies conducted in these three years have shown that CE is often misdiagnosed, especially in its rarer forms such as bone CE. Our group headed a multicenter study on the clinical management of this severely debilitating form of the disease to start building a consensus on the treatment and management of these patients. We also showed the safety of the “watch and wait” approach for the management of inactive cysts of the liver by updating previously published data. Another publication addresses our experience with the clinical management of cysts close to the Inferior Vena Cava (IVC), showing that the rate of IVC-related complications in our center was zero if patients were adequately treated, and that a stage-specific approach is also valid for this particular localization. Regarding the epidemiology of CE, I have worked with Kazakh colleagues to publish data on the disease from the National Kazakh registry of CE, a publication that hopefully will serve to orient public health efforts in the country in the future. Another publication deals with the public health implications of Albendazole shortages in the treatment of CE – a problem which is not only restricted to Italy. On serology, two publications are presented: one on the field use of Rapid Diagnostic Tests as confirmatory tests for the diagnosis of CE – a study that was never before carried out. The other on the different performance of diagnostic tests used for the serological diagnosis of CE. Finally, a preliminary study on the alterations of miRNA expression levels in patients with CE is also included.The thesis illustrates the results of three years of clinical research in the field of Cystic Echinococcosis (CE). During these three years my work as a PhD student has mainly focused on three different aspects of CE-related research: CE epidemiology, clinical management, and studies on CE diagnosis with particular regard to serology and new molecular tools for the diagnosis of CE. The first presented publication analyzed the state of the art on CE-related research in the Mediterranean area and showed that much was left to be done about the three topics I focused on during my PhD. The studies conducted in these three years have shown that CE is often misdiagnosed, especially in its rarer forms such as bone CE. Our group headed a multicenter study on the clinical management of this severely debilitating form of the disease to start building a consensus on the treatment and management of these patients. We also showed the safety of the “watch and wait” approach for the management of inactive cysts of the liver by updating previously published data. Another publication addresses our experience with the clinical management of cysts close to the Inferior Vena Cava (IVC), showing that the rate of IVC-related complications in our center was zero if patients were adequately treated, and that a stage-specific approach is also valid for this particular localization. Regarding the epidemiology of CE, I have worked with Kazakh colleagues to publish data on the disease from the National Kazakh registry of CE, a publication that hopefully will serve to orient public health efforts in the country in the future. Another publication deals with the public health implications of Albendazole shortages in the treatment of CE – a problem which is not only restricted to Italy. On serology, two publications are presented: one on the field use of Rapid Diagnostic Tests as confirmatory tests for the diagnosis of CE – a study that was never before carried out. The other on the different performance of diagnostic tests used for the serological diagnosis of CE. Finally, a preliminary study on the alterations of miRNA expression levels in patients with CE is also included

Treatment with anti-SARS-CoV-2 monoclonal antibodies in pregnant and postpartum women: first experiences in Florence, Italy

PURPOSE: Pregnant and postpartum women are at increased risk of developing severe COVID-19. Monoclonal antibodies (mAbs) are now widely used in high-income countries to treat mild to moderate COVID-19 outpatients at risk for developing severe disease. Very few data are available on the use of mAbs in special populations, including pregnant and postpartum women. Here we present our early experience with mAbs in these two populations. METHODS: Electronic records of pregnant and postpartum women treated with mAbs at Careggi University Hospital, Florence, were retrieved. Relevant data were extracted (age, presence of risk factors for COVID-19, oxygen support, mAb type, gestational age, and pregnancy status). When available, outcomes at 28 days after administration were also included. RESULTS: From March 1st to September 30th 2021, eight pregnant and two postpartum women have been treated with mAbs at our center. The median age was 31 years (IQR 30–33.5, range 29–38), median gestational age was 24 weeks. Seven patients had additional risk factors. According to the Italian disposition, all patients received casirivimab/imdevimab, with five receiving a 2.4 mg dose and five receiving a 8 g dose. Eight patients improved. One developed myocarditis, considered a COVID-19 complication. Another required a transient increase of low flow oxygen support before improving and being discharged. At a 28 days follow-up, all patients were clinically recovered. We did not observe mAbs related adverse events. CONCLUSION: Although preliminary data should be interpreted with caution, it is remarkable how mAbs were well tolerated by pregnant women with COVID-19. Further data on mAbs in this special population should be collected but the use of mAbs in pregnant and postpartum patients should be considered. Even thus oral antivirals are becoming available, they are not recommended in pregnant and postpartum women. This population may specifically benefit from treatment with last generation mAbs

Watch and wait approach for inactive echinococcal cyst of the liver: An update

Human cystic echinococcosis (CE) is a chronic, complex and neglected infection causing severe disease in humans. Hepatic CE cysts are detected and classified mainly by using ultrasound. Expert opinion and published data suggest that uncomplicated inactive liver cysts do not require treatment and only need to be monitored over time ("Watch and Wait"). Here we update our findings as published in 2014 on the "Watch and Wait" approach applied to inactive, asymptomatic cysts of the liver to keep the medical community informed. Clinical data of patients who accessed the World Health Organization Collaborating Center for CE at the University of Pavia-San Matteo Hospital Foundation from January 1991 to October 2017 were analyzed. Inclusion criteria were presence of one or more inactive uncomplicated cysts in the liver (CE4 or CE5), without any history of previous treatment, and an ultrasound-based follow-up of at least 24 months. Fifty-three patients with 66 inactive cysts fulfilled the inclusion criteria. Of these, 11 patients are newly described here; 37 were part of our previously described cohort and the follow-up for 17 of them was further extended; and five were excluded from the previously published analysis as their follow-up was too short, but could be included now. Without the need for treatment and without development of complications, 98.5% of cysts remained inactive over time. In only one patient (1.9% of patients), a reactivation of one cyst (1.5% of cysts) was observed