Macrolides in the treatment of children with Mediterranean spotted fever

Till now there is not a gold standard therapy for Mediterranean spotted fever (MSF) in children. Standard treatment for MSF is the administration of tetracycline or chloramphenicol, however both these drugs can cause significant adverse effects in children (tetracyclines can cause staining of teeth, chloramphenicol severe hematological adverse events such as aplastic anemia, gray baby syndrome and hemolytic anemia in patients with the Mediterranean form of G6PD deficiency). We conducted two randomized clinical trials; the first compared clarithromycin versus chloramphenicol: mean time to defervescence was 36.7 +/- 18.1 h in the clarithromycin group and 47.1+/- 21.9 h in the chloramphenicol group (P= 0.047). The second trial compared clarithromycin versus azithromycin and did not show any statistically significant difference: mean time to defervescence was 46.2 +/- 36.4 h in the clarithromycin group and 39.3 +/- 31.3 h in the azithromycin group (P= 0.34). On the basis of these studies we think that clarithromycin and azithromycin could constitute an acceptable alternative to chloramphenicol and to tetracyclines for the treatment of MSF in childre

Childhood Mediterranean visceral leishmaniasis

Visceral leishmaniasis (VL) is endemic in areas bordering the Mediterranean Sea (Spain, Italy, France, Greece, Morocco, Tunisia) where it is caused by Leishmania infantum and it is transmitted by the bite of hematophagous sandfly belonging to Phlebotomus spp.; dog constitutes the main reservoir of the infection. In comparison with the past, when VL was typically observed more frequently in children, the current ratio of childhood to adult cases is approximately 1:1. The onset of the disease is characterized by a non-specific initial symptomatology; fever, pallor and splenomegaly are always present. Pancytopenia is present very often; the laboratory diagnosis is established by serological tests (indirect fluorescent-antibody assay, immunoassay test, indirect hemagglutination assay) and by demonstration of Leishmania parasites by microscopy, culture or polymerase chain reaction (PCR) in the bone marrow aspirates. The use of PCR performed on peripheral blood has been reported to be highly sensitive for the diagnosis and the follow up of children with VL. Pentavalent antimonial drugs have been used for many decades as standard treatment for VL; in Italy liposomal amphotericin B (AmBisome) is nowadays considered the first-line treatment for V

Direct-acting antivirals and visceral leishmaniasis: A case report

Background: Visceral leishmaniasis is a vector-borne parasitic disease caused by protozoa belonging to the genus Leishmania. The clinical presentation of visceral leishmaniasis strictly depends on the host immunocompetency, whereas depressive conditions of the immune system impair the capability to resolve the infection and allow reactivation from sites of latency of the parasite. Case presentation: We describe a case of visceral leishmaniasis (VL) that occurred in a patient with chronic hepatitis C treated with direct-acting antiviral drugs (DAA). The hypothesized mechanism is the alteration of protective inflammation mechanisms secondary to DAA therapy. Downregulation of type II and III IFNs, their receptors, which accompany HCV clearance achieved during treatment with sofosbuvir and ribavirin might have a negative impact on a risk for reactivation of a previous Leishmania infection. We know indeed that IFN-\u3b3 is important to enhance killing mechanisms in macrophages, which are the primary target cells of Leishmania. Conclusion: Since VL is endemic in Sicily as well as in other countries of the Mediterranean basin, physicians should be aware of the possible unmasking of cryptic Leishmania infection by DAAs

Trends of influenza B during the 2010–2016 seasons in 2 regions of north and south Italy: The impact of the vaccine mismatch on influenza immunisation strategy

Influenza A and B viruses are responsible for respiratory infections, representing globally seasonal threats to human health. The 2 viral types often co-circulate and influenza B plays an important role in the spread of infection. A 6-year retrospective surveillance study was conducted between 2010 and 2016 in 2 large administrative regions of Italy, located in the north (Liguria) and in the south (Sicily) of the country, to describe the burden and epidemiology of both B/Victoria and B/Yamagata lineages in different healthcare settings. Influenza B viruses were detected in 5 of 6 seasonal outbreaks, exceeding influenza A during the season 2012–2013. Most of influenza B infections were found in children aged ≤ 14 y and significant differences were observed in the age-groups infected by the different lineages. B/Victoria strains prevailed in younger population than B/Yamagata, but also were more frequently found in the community setting. Conversely, B/Yamagata viruses were prevalent among hospitalized cases suggesting their potential role in the development of more severe disease. The relative proportions of viral lineages varied from year to year, resulting in different lineage-level mismatch for the B component of trivalent influenza vaccine. Our findings confirmed the need for continuous virological surveillance of seasonal epidemics and bring attention to the adoption of universal influenza immunization program in the childhood. The use of tetravalent vaccine formulations may be useful to improve the prevention and control of the influenza burden in general population

Rickettsia typhi and Haemophagocytic Syndrome

Appropriate therapy (dexamethasone, cyclosporin, and etoposide) could save the patient in those cases in which the pathogen-direct therapy has not been sufficient by itself to control the disease

First case of Mediterranean spotted fever-associated rhabdomyolysis leading to fatal acute renal failure and encephalitis

Mediterranean spotted fever (MSF) is a tick-borne zoonosis caused by Rickettsia conorii. In Italy, about 400 cases are reported every year and nearly half of them occur in Sicily, which is one of the most endemic regions. Although MSF is mostly a self-limited disease characterized by fever, skin rash, and a dark eschar at the site of the tick bite called a 'tache noire', serious complications are described, mainly in adult patients. Nevertheless, severe forms of the disease with major morbidity and a higher mortality risk have been described. We report a fatal case of MSF complicated by rhabdomyolysis, acute renal failure, and encephalitis in an elderly woman

Rickettsiosis with Pleural Effusion: A Systematic Review with a Focus on Rickettsiosis in Italy

Background: Motivated by a case finding of Mediterranean spotted fever (MSF) associated with atypical pneumonia and pleural effusion in which Rickettsia conorii subsp. israelensis was identified by molecular methods in the pleural fluid, we wanted to summarize the clinical presentations of rickettsiosis in Italy by systematic research and to make a systematic review of all the global cases of rickettsiosis associated with pleural effusion. Methods: For the literature search, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. We chose to select only the studies published in last 25 years and confirmed both with serological and molecular assays. Results: Human cases of rickettsiosis in Italy were reported in 48 papers describing 2831 patients with very different clinical presentations; the majority was MSF accounted to R. conorii and was reported in Sicily. Pleural effusion associated with infection with microorganisms belonging to Rickettsiales was described in 487 patients. It was rarely associated with microorganisms different from O. tsutsugamushi; also rarely, cases of scrub typhus were reported outside Southeast Asia and in the largest majority, the diagnosis was achieved with serology. Conclusions: MSF, especially when caused by R. conorii subsp. israelensis, may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis

Kawasaki disease recurrence in the COVID-19 era: a systematic review of the literature

Kawasaki disease (KD) is a vasculitis of unknown origin of small and medium caliber blood vessels, especially involving coronary arteries and is the leading cause of acquired heart disease in childhood in developed countries. Although rarely, it can recur: most recurrences occur within 2 years of the initial episode. No data are available on incidence of recurrent KD in Europe and multiple recurrences are rarely seen. We reviewed the medical literature on Kawasaki disease recurrence and reported a new case of Kawasaki disease recurrence in a child with SARS-CoV-2 infection. We believe that in our case SARS Cov2 acted as a trigger capable to determine, in a genetically susceptible individual, a second recurrence of the disease. In the Covid-19 era we affirm the importance for Kawasaki disease to be tested for SARS Cov2 infection

Delayed diagnosis of extrapulmonary tuberculosis in a 32-year-old man with knee pain

A 32-year-old Bangladeshi male was admitted at our emergency department for trauma of the left knee. The radiographs showed absence of fracture, and presence of an indeterminate oval lucency in the proximal tibia. Further examinations were suggested, but the patient refused. 6 months later, the patient re-presented at our emergency department. A CT scan showed progression of musculoskeletal involvement and spread to the liver. This case underlines the importance of considering tuberculosis in the differential diagnosis of indeterminate bone lesions in immigrant patients