primary cervicofacial nocardiosis due to nocardia asteroides in an adult immunocompetent patient

Sir, The Nocardia species are aerobic, lamentous grampositive bacteria, irregularly acid-fast staining that belong to the order Actinomycetales. Normally, Nocardia spp. are soil saprophytes, but N. asteroides may be found in the normal ora of the oral cavity and upper respiratory tract. Four species of Nocardia are pathogenic in man: N. asteroides, N. brasiliensis, N. caviae and N. madurae (1). N. asteroides is usually the agent of systemic pulmonary infections in immunocompromised hosts, while N. brasiliensis is the responsible agent in 74% of all cutaneous manifestations (1, 2). The skin is generally secondarily involved in disseminated systemic pulmonary diseases, due to haematogenous spread of N. asteroides, but it can also be primarily aVected. Primary cutaneous nocardiosis (PCN) accounts for only 5% of all nocardial infections and is caused mainly by N. brasiliensis (3, 4). PCN is characterized by numerFig. 1. In ammatory and ulcerative lesion of the nose. ous clinical manifestations: chronic mycetoma, super cial abscesses and cellulitis and lymphocutaneous increased ESR (93mm/h). Paraneoplastic serological variants. The last of these manifestations includes the markers, immunological investigations and HIV-1/2 more common sporotrichoid form (nodules along the serology were negative. Hemocultures were also lymphatic drainage) and the rarer cervicofacial variant. negative. We report an unusual case of primary cervicofacial Skull and chest X-rays were negative while ultrasononocardiosis caused by N. asteroides in an adult graphy revealed gross hypoecogenic non-homogeneous immunocompetent man. areas (colliquated lymph nodes) extending to the subfascial area. Sonography also showed numerous colliquated CASE REPORT lymph nodes in the right laterocervical region as well as a colliquative involvement of both the parotides and A 79-year-old man was admitted to our department because of fever and a necrotic ulcerative lesion of the submandibular lymph nodes. Computerized axial tomography of the head con rmed all the data and again dorsum of his nose. The borders were vegetant, in ltrated on palpation and a purulent exudate was easily showed abscesses of the left masseter muscle and the left submandibular salivary gland. obtained through compression. Numerous sparse tiny pustules and little pus-draining sinuses were peripherHistology of a skin biopsy taken from the borders of the ulcer only revealed a dense diVuse in ammatory ically sparse around the ulcerative lesion (Fig. 1). The in ammatory oedema involved the left cheek and the in ltrate of neutrophils and lymphocytes in the deep dermis, with abscess formation. No fungic elements were lower eyelid. A hardened swelling of the left mandibular angle and some hard, enlarged, latero-cervical lymph observed with PAS staining. Endovenous therapy with amoxicillin/clavulanic acid nodes were present. History revealed that the patient had had a bicycle 6.6 g/day, amikacin 1 g/day and teicoplanin 800mg/day was immediately started. A week later a slight improveaccident 15 days earlier, causing wounds on his forehead, nose and left cheek. The wounds had healed rapidly ment of the purulent and in ammatory aspects of the facial lesions was observed but the laterocervical tumewith common antiseptic medications. Blood sample examination revealed white blood factions had worsened and required surgical drainage. Cultures of purulent exudate from the nose ulcer, cells 13 109/l (60% neutrophils, 25% monocytes) an

The shed P2X7 receptor is an index of adverse clinical outcome in COVID-19 patients

Introduction: The pathophysiology of the Corona Virus Disease 2019 (COVID-19) is incompletely known. A robust inflammatory response caused by viral replication is a main cause of the acute lung and multiorgan injury observed in critical patients. Inflammasomes are likely players in COVID-19 pathogenesis. The P2X7 receptor (P2X7R), a plasma membrane ATP-gated ion channel, is a main activator of the NLRP3 inflammasome, of the ensuing release of inflammatory cytokines and of cell death by pyroptosis. The P2X7R has been implicated in COVID-19-dependent hyperinflammation and in the associated multiorgan damage. Shed P2X7R (sP2X7R) and shed NLRP3 (sNLRP3) have been detected in plasma and other body fluids, especially during infection and inflammation. Methods: Blood samples from 96 patients with confirmed SARS-CoV-2 infection with various degrees of disease severity were tested at the time of diagnosis at hospital admission. Standard haematological parameters and IL-6, IL-10, IL-1β, sP2X7R and sNLRP3 levels were measured, compared to reference values, statistically validated, and correlated to clinical outcome. Results: Most COVID-19 patients included in this study had lymphopenia, eosinopenia, neutrophilia, increased inflammatory and coagulation indexes, and augmented sNLRP3, IL-6 and IL-10 levels. Blood concentration of sP2X7R was also increased, and significantly positively correlated with lymphopenia, procalcitonin (PCT), IL-10, and alanine transaminase (ALT). Patients with increased sP2X7R levels at diagnosis also showed fever and respiratory symptoms, were more often transferred to Pneumology division, required mechanical ventilation, and had a higher likelihood to die during hospitalization. Conclusion: Blood sP2X7R was elevated in the early phases of COVID-19 and predicted an adverse clinical outcome. It is suggested that sP2X7R might be a useful marker of disease progression

Hospital discharge in patients at risk of surgical site infection: antimicrobial stewardship at Ferrara University Hospital, Italy.

Introduction. The appropriate use of antibiotics is a global priority in order to avoid antibiotic resistance. Up to 50% of antibiotics usage in hospital is inappropriate (e.g. prolonged surgical prophylaxis, “defensive medicine” approach).In 2015, at the Ferrara University Hospital, an antimicrobial stewardship intervention to reduce antimicrobial prescription at the time of hospital discharge in patients at risk of surgical site infection was implemented. This programme included: update meetings for health professionals, focused meetings for critical wards, reviews of some surgical prophylaxis protocols, recommendations to reduce broad-spectrum antimicrobials use, and planning of an audit. The purpose of this study has been to evaluate the effect of this antimicrobial stewardship programme.Methods. To evaluate the effect of this intervention, a study has been carried out including inpatients in surveillance for surgical site infection who had surgery during the last quarter of 2014 (pre-intervention group; 461 patients) and of 2015 (post-intervention group; 532 patients).Results. The proportion of patients with prescription of at least one antimicrobial at discharge decreased from 33% to 24.4% (p=0.002). The most prescribed categories of antimicrobials in both groups were the combination of penicillins with beta-lactamase inhibitors (with prescription rate reduced from 21.9% to 18%; p=0.13) and fluoroquinolones (from 8.2% to 3.2%; p<0.001). Conclusions. This statistically significant reduction in antimicrobial prescription after the intervention was registered without a change in surgical site infections rate (from 3.5% to 3.2%; p=0.08). Therefore, this intervention was effective in reducing the antimicrobial prescription at discharge, without affecting patients' safety

Oral Microbiome Dysbiosis Is Associated With Symptoms Severity and Local Immune/Inflammatory Response in COVID-19 Patients: A Cross-Sectional Study

The human oral microbiome (HOM) is the second largest microbial community after the gut and can impact the onset and progression of several localized and systemic diseases, including those of viral origin, especially for viruses entering the body via the oropharynx. However, this important aspect has not been clarified for the new pandemic human coronavirus SARS-CoV-2, causing COVID-19 disease, despite it being one of the many respiratory viruses having the oropharynx as the primary site of replication. In particular, no data are available about the non-bacterial components of the HOM (fungi, viruses), which instead has been shown to be crucial for other diseases. Consistent with this, this study aimed to define the HOM in COVID-19 patients, to evidence any association between its profile and the clinical disease. Seventy-five oral rinse samples were analyzed by Whole Genome Sequencing (WGS) to simultaneously identify oral bacteria, fungi, and viruses. To correlate the HOM profile with local virus replication, the SARS-CoV-2 amount in the oral cavity was quantified by digital droplet PCR. Moreover, local inflammation and secretory immune response were also assessed, respectively by measuring the local release of pro-inflammatory cytokines (L-6, IL-17, TNFα, and GM-CSF) and the production of secretory immunoglobulins A (sIgA). The results showed the presence of oral dysbiosis in COVID-19 patients compared to matched controls, with significantly decreased alpha-diversity value and lower species richness in COVID-19 subjects. Notably, oral dysbiosis correlated with symptom severity (p = 0.006), and increased local inflammation (p < 0.01). In parallel, a decreased mucosal sIgA response was observed in more severely symptomatic patients (p = 0.02), suggesting that local immune response is important in the early control of virus infection and that its correct development is influenced by the HOM profile. In conclusion, the data presented here suggest that the HOM profile may be important in defining the individual susceptibility to SARS-CoV-2 infection, facilitating inflammation and virus replication, or rather, inducing a protective IgA response. Although it is not possible to determine whether the alteration in the microbial community is the cause or effect of the SARS-CoV-2 replication, these parameters may be considered as markers for personalized therapy and vaccine development

Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry

Skin and soft tissue infections (SSTIs) represent a wide range of clinical conditions characterized by a considerable variety of clinical presentations and severity. Their aetiology can also vary, with numerous possible causative pathogens. While other authors previously published analyses on several types of SSTI and on restricted types of patients, we conducted a large nationwide surveillance programme on behalf of the Italian Society of Infectious and Tropical Diseases to assess the clinical and microbiological characteristics of the whole SSTI spectrum, from mild to severe life-threatening infections, in both inpatients and outpatients. Twenty-five Infectious Diseases (ID) Centres throughout Italy collected prospectively data concerning both the clinical and microbiological diagnosis of patients affected by SSTIs via an electronic case report form. All the cases included in our database, independently from their severity, have been managed by ID specialists joining the study while SSTIs from other wards/clinics have been excluded from this analysis. Here, we report the preliminary results of our study, referring to a 12-month period (October 2016–September 2017). During this period, the study population included 254 adult patients and a total of 291 SSTI diagnoses were posed, with 36 patients presenting more than one SSTIs. The type of infection diagnosed, the aetiological micro-organisms involved and some notes on their antimicrobial susceptibilities were collected and are reported herein. The enrichment of our registry is ongoing, but these preliminary results suggest that further analysis could soon provide useful information to better understand the national epidemiologic data and the current clinical management of SSTIs in Italy

INTRACEREBRAL TOXOPLASMA AND CRYPTOCOCCAL COINFECTION IN IMMUNOCOMPROMISED PATIENT WITH SISTEMIC LUPUS ERYTHEMATOSUS.

Objectives: Despite a significant increase in the survival rate of patients with systemic lupus erythematosus (SLE), opportunistic infections represent a significant cause of morbidity and mortality. Risk factors include immunosuppressive theraphies as well as some manifestations of active SLE itself. Clinicians need to be aware about the possibility of polymicrobial infections which may cause diagnostic and therapeutic delay. Methods: We report a case of intracerebral coinfection with Cryptococcus neoformans and Toxoplasma gondii in a 29-years-old man with SLE and congenital IgA deficit, under treatment with steroids. The patient, suffering from one week of fever, vomit and diarrhea, was admitted to our hospital for a syncopal episod following which did not regain consciousness. A neurological consultancy took over stiffness in all four limbs and lockjaw, coma with decortication reaction to painful stimuli, mydriatic pupils. Brain MRI with gadolinium contrast showed the presence of interhemispheric multiple focal lesions enhancement. Results: Cerebrospinal fluid (CSF) examinations revealed 24 white blood cells/μl, glucose 1 mg/dl and protein 266 mg/dl. An India-ink preparation of CSF disclosed mucinous capsule of Cryptococcus as a translucent halo surrounding budding yeast. A latex agglutination test was positive for cryptococcal antigen at a diluition of 1:4096 and CSF culture grew C. neoformans. HIV serology was negative but lymphocyte and CD4 lymphocyte count were 308/μl and 190/μl, respectively. CD4/CD8 ratio was 2.00. He was treated with liposomal amphotericin B (2 mg/kg/die) and dexamethasone (32 mg/die). Because of severe immunosuprression, other opportunistic pathogens were investigated. A qualitative in house PCR resulted positive for T. gondii DNA (B1 gene) in CSF, peripheral blood mononuclear cells and serum. Anamnestic T. gondii serology was negative. The therapeutic regimen was promptly strengthened with cotrimoxazole (20mg/kg/die+100mg/Kg/die), but a new CT scan demonstrated a diffuse cerebral swelling. Because of severe general impairment, the patient died two days later. Conclusions: Patients with severe SLE under immunosuppressive treatment with steroids may undergo acute infections including those from virus, common bacteria and Mycobacteria, fungi (i.e C. neoformans) and parasites (i.e T. gondii) which can occur alone or rarely in combination. In this regard, only one case of intracerebral coinfection with Burkholderia pseudomalley and C. neoformans has been recently described. To our knowledge, the presented case is the first describing an intracerebral coinfection with both C. neoformans and T. gondii in a patient with SLE. Monitoring CD4 lymphocyte count is highly recommended in patients with SLE under immunosuppressive treatment; if lower than 200/μl, they should assume cotrimoxazole prophylaxis, as HIV+ patients. In case of detection of brain lesions, rapid molecular diagnosis for more than one opportunistic infection should be taken into account as failure to timely recognition of coinfections may lead to insufficient treatment and affect outcome

Health education and HIV test offer in a population of refugees and asylum seekers: an experience in Ferrara area.

Issue: Migration flows are increasing and involve a wide range of populations, such as workers, refugees, students, undocumented migrants and others, each with different health determinants, needs and levels of vulnerability. Among these, there are HIV/AIDS infection and other sexually transmitted disease (STDs): traditional approaches are insufficient to address these complex challenges. In Italy, 30% of new HIV infections occurr in foreign people. Major concern is the limited access to health services and less information about transmission of HIV and other STDs. In Ferrara, the majority of refugees and asylum seekers are young men in the sexually active stage of their lives. Our aim is to improve HIV/AIDS-related knowledge within migrants, refugees and asylum seekers, to favour access to public health service and HIV/STDs test. Description of the problem: A collaboration was established between 2 public services in Ferrara area: HIV/AIDS outpatient unit of S.Anna Hospital and CAmelot association that provides assistance for refugees and coordinates a public information point for migrants. Major problems were identified: accessibility of health service, preventive care, health education, linguistic and cultural barriers. On this basis, a collaborative project was proposed and included training courses on HIV/AIDS and STDs for healthcare workers and cultural mediators, recruitment of staff for migrant’s health education, encourage and offer screening for HIV and STDs. Results: The project started in may 2013: an interdisciplinary staff was identified (infectious disease health workers, cultural mediators, experts in international migration human rights). The staff had meetings with migrants in order to give informations about health system, migrants rights, HIV/AIDS and STDs prevention; each meeting was 1.30 hour long. -246/388 (63,4%) migrants accepted to participate in the project: they were male, age 20-28, 88% from Africa (Nigeria, Senegal, Mali), 12% from Pakistan. -2/246 (0,8%) were found HIV +. This confirm that most of migrants acquires HIV infection in the new country. -32/246 (13%) were HBsAg +: new tests have been performed in order to better define their clinical status. -56/246 (22,7%) were anti-HBs positive and thus protected, 158/246 (64,2%) migrants were negative for HBV infection and sent to the vaccination centre in order to prevent possible new infections do the potential promiscuity with people with HBV active disease. Lessons: The health of migrants is a major concern for host countries. We need programs to reduce barriers to health services and to offer information about HIV/STDs transmission. Migrants agree with this form of information, in particular they appreciate the presence of cultural mediators to explain health service opportunities, HIV/STDs prevention and transmission. This confirms the need to improve the project and the possibility to extend these initiatives to other health problems. Message: Migration flows are increasing and involve a wide range of populations. The project aim is to improve HIV/AIDS-related knowledge within migrants, refugees and asylum seekers, to favour access to public health service and HIV/STDs tes

COVID-19 in eastern Emilia: an unusual epidemiology in Northern Italy

The Authors report the unusual epidemiological features of the COVID 19 in an area of the Northern Italy. The reasons of the lower prevalence compared to other areas are described. A set of strategies have proven successful in limiting cases

FOLLOW-UP A BREVE-LUNGO TERMINE DELL’INFEZIONE NEUROINVASIVA DA WEST NILE VIRUS NEL NORD-EST ITALIA

Premessa La “West Nile Fever” è una malattia provocata West Nile virus (WNV), Flavivirus isolato nel 1937 nel distretto West Nile (Uganda) e diffuso in Africa, Asia occidentale, Europa, Australia e America. La maggior parte delle infezioni da WNV, restano asintomatiche, mentre circa il 20% presenta febbre, cefalea, nausea, vomito, linfadenopatia, rash cutaneo. Meno dell’1% delle persone sintomatiche sviluppa una forma neuro-invasiva severa (WNND) caratterizzata da quadri meningitici, encefalitici, poliomielitici. Nonostante le numerose acquisizioni riguardanti le caratteristiche cliniche della fase acuta di malattia, pochi sono i dati sul “long-term follow-up” della malattia neuro invasiva e le sue sequele funzionali. Obiettivo dello studio Analizzare l’andamento clinico nel breve-lungo periodo dei soggetti ricoverati presso le Malattie Infettive di Rovigo e Ferrara (Agosto 2008-Dicembre 2010) e dimessi con diagnosi di WNND. Sono stati valutati 14 pazienti con i seguenti parametri: 1) caratteristiche demografiche: età, sesso, luogo di residenza, stagionalità; 2) comorbidità significative per WNND; 3) caratteristiche cliniche: manifestazioni all’esordio, durante la degenza e complicanze; 4) diagnosi: metodi diagnostici, tempo intercorso tra ricovero e diagnosi (latenza diagnostica); 5) outcome a breve e a lungo termine. I pazienti sono stati suddivisi in 2 gruppi: quadri di meningo-encefalite (Gruppo 1; 7 casi) e di meningo-encefalite associata a paralisi flaccida acuta (Gruppo 2; 7 casi). Risultati Dei 14 pazienti ricoverati, 10 (64%) erano uomini e 4 (36%) donne; età mediana 70,5 a (range 47-84); 68 a nel Gruppo 1, 73 a nel gruppo 2. 13 soggetti erano italiani,1 Rumeno. Tutti i soggetti presentavano comorbidità per WND. Complessivamente, i ricoveri sono avvenuti tra agosto e dicembre (5 ad Agosto, 8 a Settembre, 1 a Dicembre). La durata media di ospedalizzazione è stata significativamente diversa fra il 1° e 2° Gruppo (36 vs 47 gg) come pure vi è stata una differenza significativa nel numero delle complicanze ( > nel Gruppo 2). In un follow-up di 32 mesi (media, 1-52) si sono verificati 7 decessi; 3 (21%) durante la degenza, 4 (28%) dopo la dimissione (range 7 giorni-12 mesi), con un tasso di letalità complessivo del 43%. L’età (>64 a) è risultato l’ unico fattore significativamente correlato alla mortalità. La Tabella 1 mostra gli “outcome” a breve e lungo termine di tutti i pazienti. Conclusione La malattia neuro invasiva da WNV è una patologia ad elevata mortalità, sia in fase acuta che cronica, gravata dallo sviluppo di numerose sequele neurologiche, più marcate e debilitanti nei pazienti con paralisi flaccida acuta che nel lungo termine, nella nostra casistica, non hanno mostrato alcun recupero delle funzioni fisiche e perdita dell’autosufficienza. In accordo con la letteratura, la popolazione anziana, di sesso maschile e con anamnesi positiva per patologie pregresse, si è dimostrata essere quella più suscettibile alla malattia neuro invasiva da WNV