Epstein-Barr Virus Reactivation after Infliximab in Rheumatoid Arthritis: A Case Report

TNF-alpha blockers represent one of the most important therapeutic strategies for rheumatoid arthritis, but their use has raised the question about their safety profile, particularly in respect to viral infections/reactivations. We describe the case of a patient who developed a symptomatic EBV reactivation 11 days after the first infusion of infliximab

Varicella zoster virus reactivation antedating ipsilateral brainstem stroke

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The relevance of molecular genotyping to allocate cases in a suspected outbreak of Legionella pneumonia in patients with prolonged immunosuppressive therapy

Three cases of pneumonia caused by Legionella pneumophila serogroup 1 (Lp1) in immunosuppressed patients with repeated hospitalization were suspected as a healthcare-associated cluster. The environmental investigation did not reveal the presence of legionellae in the hospital patient rooms. Water samples collected from the homes of two patients were also negative for Legionella spp. In the absence of environmental strains potentially involved in the infections, we proceeded to genotype environmental Lp1 strains isolated in the hospital during routine water sampling during the decade 2009–2019 and recovered after long-term storage at −20 °C. These 'historical' strains exhibited a high grade of similarity and stability over time, regardless of the disinfection systems. The different molecular profiles shown among the clinical and environmental strains excluded a nosocomial outbreak. The study suggests that the application of molecular typing may be a useful tool to discriminate hospital vs community-acquired cases, mostly for severely immunosuppressed patients in whom the symptomatology could be insidious and the incubation period could be prolonged. Moreover, the genotyping allowed us to exclude any link between the cases. Keywords: Legionnaires' disease, Immunosuppressed patients, Sequence-based typing, Cluster, Environmental strains, Clinical strain

Improvement of Legionnaires' disease diagnosis using real-time PCR assay: a retrospective analysis, Italy, 2010 to 2015

AimTo evaluate real-time PCR as a diagnostic method for Legionnaires' disease (LD). Detection of Legionella DNA is among the laboratory criteria of a probable LD case, according to the European Centre for Disease Prevention and Control, although the utility and advantages, as compared to culture, are widely recognised.MethodsTwo independent laboratories, one using an in-house and the other a commercial real-time PCR assay, analysed 354 respiratory samples from 311 patients hospitalised with pneumonia between 2010-15. The real-time PCR reliability was compared with that of culture and urinary antigen tests (UAT). Concordance, specificity, sensitivity and positive and negative predictive values (PPV and NPV, respectively) were calculated.ResultsOverall PCR detected eight additional LD cases, six of which were due to Legionella pneumophila (Lp) non-serogroup 1. The two real-time PCR assays were concordant in 99.4% of the samples. Considering in-house real-time PCR as the reference method, specificity of culture and UAT was 100% and 97.9% (95% CI: 96.2-99.6), while the sensitivity was 63.6% (95%CI: 58.6-68.6) and 77.8% (95% CI: 72.9-82.7). PPV and NPV for culture were 100% and 93.7% (95% CI: 91.2-96.3). PPV and NPV for UAT were 87.5% (95% CI: 83.6-91.4) and 95.8% (95% CI: 93.5-98.2).ConclusionRegardless of the real-time PCR assay used, it was possible to diagnose LD cases with higher sensitivity than using culture or UAT. These data encourage the adoption of PCR as routine laboratory testing to diagnose LD and such methods should be eligible to define a confirmed LD case

Varicella zoster virus reactivation antedating ipsilateral brainstem stroke

itor Title: Varicella zoster virus reactivation antedating ipsilateral brainstem stroke Authors: Giuliana Galassi1, Maurilio Genovese2, Marisa Meacci3, Marcella Malagoli2 Affiliations: 1Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Italy, 2Neuroradiology Service, University Hospital of Modena, Italy, 3Department of Laboratory Medicine and Patholgy, Microbiology and Virology Unit, University Hospital of Modena, Italy Corresponding Author: Giuliana Galassi, MD, Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Via P. Giardini 1455, Modena, Italy, Tel: 39-3497325802, Email: [email protected] Abstract: Varicella zoster virus (VZV) infection and reactivation are associated with a number of neurologic conditions. Unifocal large vessel infarcts may follow zoster in the trigeminal or cervical distribution as a result of transaxonal transport of virus from trigeminal or cervical afferent fibers that innervate vessels. Ophthalmic zoster (HZO) might cause ophthalmoplegic syndromes, with secondary optic neuritis. Mechanisms include local orbital muscle inflammation and, viral spread from the ophthalmic branch of the fifth nerve with associated vasculopathy. A 72-year-old man developed a vesicular rash in the territory of C5-T5-6. Within four weeks, the patient developed headache, dysphagia, left facial and extremity ataxic weakness. Magnetic resonance imaging (MRI) revealed a right pontine infarction. A 66-year-old woman presented with right-sided painfull HZO. One week later she developed complete external ophthalmoplegia and blurred vision. MRI showed ill-defined signal alteration in the retrobulbar tissue. Three weeks later, the patient was admitted because of dysarthria, deviated tongue, left-sided limb weakness, and tactile hypoesthesia. Spinal fluid contained 23 lymphocytes/mm3 and increased protein. The serum contained antibodies to VZV IgG and IgM in both cases. The patients received intravenously acyclovir with improvement. This report confirms unusual occurrence of ipsilateral brainstem stroke after VZV reactivation in immunocompetent subjects

IL MYCOARRAY: UN TEST RAPIDO PER LA DIAGNOSI SIEROLOGICA DI MICOSI ENDEMICHE

Introduzione Le micosi da funghi dimorfi, estremamente rare in Europa, sono rappresentate da casi di importazione, con l’eccezione della istoplasmosi per la quale sono stati segnalati anche casi autoctoni. La bassa frequenza, in combinazione con l’aspecificità delle manifestazioni cliniche, rende difficile una diagnosi rapida. Scopo del presente studio è la valutazione dell’utilizzo del saggio mycoarray (1) come strumento multiparametrico e rapido, a supporto della sierologia convenzionale, nella diagnosi di laboratorio delle micosi endemiche. Metodi Antigeni fungini (H. capsulatum, C. immitis, B. dermatitidis e P. brasiliensis), diluizioni scalari di anticorpi IgG e IgM e controlli sono stati deposti su vetrini microarray per mezzo di un sistema robotizzato ad alta precisione. I vetrini così ottenuti sono stati cimentati col siero, opportunamente diluito, e successivamente con anticorpi secondari marcati con fluorofori per rivelare l’avvenuta formazione degli immunocomplessi. Il segnale è stato acquisito mediante uno scanner, quantificato ed analizzato per mezzo di un apposito software. Risultati Il mycoarray ha mostrato elevate sensibilità e specificità: un primo studio retrospettivo, condotto su sieri da pazienti con diagnosi certa di istoplasmosi o di coccidioidomicosi, ha fornito risultati consistenti con i dati clinici e di laboratorio, acquisiti con la diagnostica di routine. Indagini su ulteriori campioni da casi clinici “sospetti”, analizzati con il mycoarray, hanno fornito risultati originali utili per la diagnosi definitiva di micosi endemica. Conclusioni Il mycoarray presenta una serie di peculiarità (miniaturizzazione, multiparametricità e rapidità di esecuzione) che lo rendono estremamente utile come strumento di laboratorio a sussidio del percorso convenzionale nella diagnosi di micosi primitive, specialmente in zone a bassa endemicità. Ringraziamenti Lavoro in parte supportato da MIUR, PRIN-200985J87J Bibliografia (1) Ardizzoni et al., (2011) New Microbiol, 34:307-16

Repeated Quantiferon-TB Gold In-Tube Tests In Routine Clinical Practice: A Five Years Experience

Introduction. Interferon Gamma Release Assays (IGRAs) are increasingly being used as diagnostic aids for Mycobacterium tuberculosis infection. Although evidence on IGRA performance in different populations is quickly accumulating, data on their use in non-experimental settings may provide information on their performance in routine clinical practice. We reviewed the results of QuantiFERON-TB In-Tube (QTF-IT) tests at our hospital since its introduction in diagnostic routine, with particular focus on repeated tests. Methods: We extracted the anonymised electronic records of all consecutive QFT-IT performed at the Laboratory of Microbiology and Virology of University Hospital of Modena (Italy) between May 2006 and December 2010. All tests performed in both inpatients and outpatients were included in the analysis. Results: A total of 10,812 tests were performed in 8,623 individuals (mean age ± SD: 46±23 years; 52.8% male). Among subjects who underwent single testing (n=7,039, 81.6%), 69.7% were negative, 22.5% positive, 7.4% indeterminate and 0.1% not interpretable due to high background in the negative control (0.3% of all tests were not performed due to missing or inadequate samples). In 1,584 (18.4%) subjects (mean age ± SD: 41±23 years; 56.1% male) QFT-IT was repeated at least once: in this group, there was a significantly higher proportion of indeterminate QFT-IT results (11.6%) at first testing, as compared to subjects with single tests (p<0.0001). In most cases (72.5%) the second QFT-IT provided valid concordant results (53.5% concordant negative; 19.0% concordant positive); conversions (from negative to positive) and reversions (from positive to negative) occurred in 3.7% and 7.3% of patients, respectively. Indeterminate results were more likely to become negative instead of positive (7.1% vs. 0.8%; p<0.0001); 3.8% of negative results became indeterminate at second testing. Conclusions: In this non-experimental routine setting, repeated QFT-IT confirmed previous results in most cases, providing little additional clinical information. Indeterminate QFT-IT results were more frequently negative than positive at repeated testing, thus suggesting that most indeterminate tests do not mask a positive result

The protein “mycoarray”: a novel immunoassay for the serological diagnosis of primitive invasive mycoses

Objectives. Invasive fungal infections are an important cause of morbidity and mortality in an increasingly higher number of patients, also because of difficulties in providing a rapid and appropriate diagnosis. In some cases, detection of a specific antibody response is a crucial diagnostic tool; however, the available serological assays often provide qualitative results only, their sensitivity and specificity are poor and long time procedures are required. In addition, patients who suffer from an invasive mycosis may have multiple infections likely underestimated by conventional diagnostic approaches. In order to couple the serology of primitive invasive mycoses to the protein microarray technology, a “mycoarray” assay has been designed and set up.Methods. Four antigen extracts (histoplasmin, coccidioidin, Coccidioides “TP” antigen and aspergillin) and the appropriate controls were spotted in various conditions onto a restricted area of a microscope slide. The printed slides were then incubated with immune sera produced in goat against each single antigen or, subsequently, with human sera (6 from patients affected by primitive invasive mycoses and 7 from healthy individuals). The occurring immunocomplexes were detected by indirect immunofluorescence.Results. The pilot experiments, conducted using the goat immune sera, allowed to establish the optimal spotting conditions for each antigen in terms of both spotting buffer and extracts’ dilution. The “mycoarrays”, obtained by spotting all the fungal antigens with the best condition, were then processed with sera either from patients or control subjects. The reactivity observed in the arrays processed with the patients’ samples was in agreement with the clinical and microbiological diagnosis; no reactivity was ever observed in the arrays processed with the negative control sera.Conclusions. The “protein mycoarray” is sensitive enough to discriminate between healthy individuals and patients affected by histoplasmosis or coccidioidomycosis. This novel diagnostic tool, because of its intrinsic features, miniaturization and multiparametricity, can contribute to cut out costs and to shorten times-to-results, with the potentiality to be included in the daily clinical practice in the near future

Quantiferon-TB Gold In-Tube Tests In Hospital Health Care Workers: A Five Years Experience

Introduction. Interferon Gamma Release Assays (IGRAs) are being largely used worldwide for the screening of tuberculosis infection among subjects likely to undergo multiple testing, such as health care workers (HCW). In theory, IGRAs should overcome the risk of false positive results due to the boosting effect, at difference with the in vivo tuberculin skin test. Evaluation of IGRA results in HCW in a non-experimental setting over several years may provide information on the real-life performance of these tests in daily practice. We reviewed the results of QuantiFERON-TB In-Tube (QTF-IT) tests performed on HCW over nearly five years, with particular focus on repeated tests. Methods: We extracted the anonymised electronic records of all consecutive QFT-IT performed on HCW between May 2006 and December 2010. All tests were done at the Laboratory of Microbiology and Virology of University Hospital of Modena (Italy). Results: A total of 1,531 tests were performed in 1,189 individuals (mean age ± SD: 37±10 years; 29% male). In 226 subjects (37±9 years; 31% male) QFT-IT was repeated at least once. Among subjects who underwent single testing (n=963, 81%), 85% were negative and 14% positive, as compared to the results at first test among subjects with repeated tests (69% negative, 27% positive; p<0.0001). In the majority of cases (84%) a second QFT-IT provided a concordant valid result. Reversion (from positive to negative) occurred more frequently than conversion (from negative to positive) (respectively, 10% vs. 4% of repeated tests). Rate of indeterminate results was extremely low, 0.4% in subjects with single testing and 1.8% at first test in subjects with multiple tests. At second testing, indeterminate QFT-IT results at first testing became negative in all but one case, which remained indeterminate. Conclusions: In this non-experimental routine setting of tuberculosis infection screening in HCW, subjects who underwent repeated tests were more likely to have a positive QFT-IT at first testing, as compared to subjects with single testing. However, a repeated QFT-IT confirmed previous results in almost all cases. Reversions occurred more often than conversions. Rate of indeterminate QFT-IT results was extremely low, thus indicating a very good technical performance of this test in HCW in a low TB prevalence area