Reemergence of Strongyloidiasis, Northern Italy

Strongyloidiasis is a helminth infection caused by Strongyloides stercoralis, a nematode ubiquitous in tropical and subtropical countries and occasionally reported in temperate countries, including Italy (1). Sources of infection are filariform strongyloid larvae present in soil contaminated by infected feces; the larvae penetrate through the skin of a human host. After the first life cycle, a process of autoinfection begins, which persists indefinitely in the host if the infection is not effectively treated. The infection can remain totally asymptomatic for many years or forever or cause cutaneous (itching and rash), abdominal (epigastric pain, pseudoappendicitis, diarrhea), respiratory (cough, recurrent asthma), and systemic (weight loss, cachexia) symptoms that can be enervating. More importantly, when host immunity is impaired because of a concurrent disease or immunosuppressive therapy (including corticosteroids, sometimes used to treat symptoms of the unrecognized infection or the concurrent eosinophilia), disseminated strongyloidiasis may occur (2\u20134), causing a massive and almost invariably fatal invasion of virtually all organs and tissues by filariform larvae and even adult worms (Figure), often combined with bacterial superinfection. This complication is believed to be rare but is probably underestimated because of the extreme variability of the clinical presentation. Although strongyloidiasis can be suspected in the presence of symptoms or eosinophilia (which is frequent but not mandatory), the low sensitivity of direct diagnostic methods often lets the disease go unrecognized (5\u20137). By far the most sensitive diagnostic tools are serologic tests: sensitivity and specificity of indirect fluorescent antibody test (IFAT) (in-house produced IFAT) are 97.4% and 97.9%, respectively, at a dilution >1/20, and 70.5% and 99.8% at a dilution >1/80 (6). A suspected case is defined by a positive antibody titer >20 (IFAT); a case is confirmed by a positive direct test result (culture in agar being the most sensitive direct technique) or by a positive antibody titer >80 (6). Despite some anecdotal reports on the presence of strongyloidiasis in Italy (1,6), reliable information about the real prevalence of the infection is lacking. After seeing several patients affected by the disease, 1 of whom died because of dissemination (Z. Bisoffi, unpub. data), we decided to carry out a preliminary rapid assessment of the extent of the problem in elderly patients with eosinophilia. During a 4-month period, from February through May 2008, every patient born in 1940 or earlier who came to the clinical laboratories of 2 contiguous health districts in northern Italy (Mantova, Lombardy Region, and Legnago, Veneto Region) for a diagnostic blood test (hematocrit and leukocyte count/formula) for whatever reason and having a eosinophil count >500 cells/\u3bcL was asked to join the study. This study was the pilot phase of a larger, multicentered study, which obtained formal approval from the Ethical Committee of Sacro Cuore Hospital of Negrar, Verona. Informed consent was required of each patient. Of the 132 patients eligible for inclusion (mean age 76.4 years, range 68\u201390 years, male:female ratio 1.6), none refused to give informed consent. Serum specimens were subjected to the IFAT for S. stercoralis at the Sacro Cuore Hospital Centre for Tropical Diseases. Unexpectedly, we found that 37 (28%) of 132 patients were positive, with titers ranging between 20 and >320 (and >80 in most cases). However, caution should be exercised in interpreting the results because the patients may not be representative of the general population. Moreover, our results are based on an indirect (although highly sensitive and specific) test. Because the reported cases involve only a few patients every year (of whom some are anecdotally reported as dying from the infection, usually unpublished), we suspect that most strongyloidiasis cases remain undetected. If relevant transmission still exists in the area, it is unknown but is unlikely because of the improvement of hygienic conditions in the past 5 decades. Reports of the infection in children or young adults with no travel history outside Italy are lacking. Strongyloidiasis in the elderly is therefore most likely to result from an infection that occurred much earlier in life, either in infancy or at a young age, while walking or working barefoot in agricultural fields. The long persistence is the consequence of the autoinfection cycle typical of this parasite as described above. The result is an important and unrecognized public health problem affecting the geriatric population of northern Italy. These preliminary results confirm the need for the already planned, multicentered study involving a larger sample and a wider geographic area

Sorafenib Therapy for Hepatocellular Carcinoma in an HIV–HCV Coinfected Patient: A Case Report

The paper reports on the coadministration of highly effective antiretroviral therapy and sorafenib for hepatocellular carcinoma in a patient coinfected with HIV and hepatitis C virus. The simultaneous administration of these therapies was well tolerated and effective

Plasmablastic Lymphoma Among HIV-Positive Patients: A Curable Entity? Results of a Single Centre's Experience

Abstract Abstract 3640 Background. Recently published data concerning Plasmablastic Lymhoma (PBL) developing in HIV-positive (HIV-pos) patients (pts) confirm the adverse prognosis both in terms of overall survival (OS) and progression free survival (PFS) of this rare entity (Castillo et al, Cancer 2012 doi: 10.1002/cncr.27551), even using an intensive treatment approach. Aims. To verify this clinical behaviour, we evaluated clinical characteristics, response to treatment and outcome of PBL HIV-pos pts admitted to our Institution. Patients and Methods. Data concerning pts affected by PBL were extracted from the database in which, since 1985, all new consecutive cases of HIV-pos lymphoma are prospectively registered. All cases were histologically reviewed and in those diagnosed before 1997 the diagnosis was confirmed according to criteria indicated by Delecluse et al (Blood 1997; 89:1413). Results. During 27 years of observation, 18 PBL HIV-pos pts were registered, 4 in the pre-HAART (before 1997) and 14 in the post HAART (after 1997) era. Median age was 36.5y (range 26–54), male/female ratio 15/3. Median time from HIV-positivity detection to PBL was 2.8y (0–24.9). Median CD4 count at PBL diagnosis was 248/mcL (13–727) and 7/18 pts (38.9%) had a CD4 count &lt;200/mcL. B-symptoms were present in 29.4% of pts and advanced stage (III-IV) in 82.5% of pts. Oral cavity involvement was observed in 47% of pts and extranodal involvement in 88%. An intermediate-high aaIPI was observed in 11/18 pts (61.1%). Two pts were not evaluable because of early death and refusal of treatment (1 pt each). Sixteen out of 18 pts were treated with CHOP or CHOP-like regimen; three received autologous stem cell transplantation (ASCT) as consolidation of first-line therapy and 2 as salvage therapy. Fifteen of 16 pts (93%) achieved a complete remission (CR) and 1 showed disease progression (PD). Three pts relapsed, at +5, +6 and +21 months respectively. After a median follow-up of 32 months (range 4–184), OS and PFS at 3y were 70.9%±12.6%SE and 56%±14.1%SE respectively. PFS was influenced neither by aaIPI (at 3y: aaIPI 0–1: 51.5%±20.4% vs aaIPI 2–3: 67.5%±15.5) nor by CD4 count (at 3y: CD4 &lt;200/mcL: 50%±20.4% vs CD4&gt;200/mcL: 60.6%±19.8%), whereas a trend for a better OS in pts with low aaIPI and CD4 count &gt;200/mcL was observed (at 3y: aaIPI 0–1: 83.3%±15.2% vs aaIPI 2–3: 59.1%±19.8%, p=0.22, and CD4 &lt;200/mcL: 50%±20.4% vs CD4&gt;200/mcL: 90.9%±8.7%, p=0.17). All of the 4 pts diagnosed in the pre-HAART era underwent chemotherapy; 3 pts died (2 of PBL and 1 of AIDS). Twelve of the 14 pts diagnosed in the post-HAART era received curative treatment; all of them achieved CR and only 1 died of an event unrelated to lymphoma or HIV (car crash). When comparing pre and post-HAART era, OS at 3y was 25%±21.6% and 92.3%±7.4% respectively (p=0.13); PFS at 3y was 25%±21.6% and 69.9%±15.4% (p=0.38). No relapses after 3y were observed. Conclusions. Our data show that, in spite of its clinical aggressiveness, PBL seems to be curable in a high proportion of pts. A low aaIPI, and a higher CD4 count as well as the use of HAART positively influenced survival, whereas PFS was similar in all the settings. Discrepancies with data of the literature may be related to the shorter interval between HIV-positivity and PBL diagnosis in comparison with the series reported by Castillo et al, and to the more aggressive treatment approach including ASCT used in this series. Further studies, with a larger number of pts, are warranted in order to confirm these observations. Disclosures: No relevant conflicts of interest to declare. </jats:sec

Point-of-care screening, prevalence, and risk factors for hepatitis B infection among 3,728 mainly undocumented migrants from Non-EU countries in northern Italy

BACKGROUND: Screening migrants from areas where hepatitis B virus (HBV) infection is endemic is important to implement preventive measures in Europe. The aim of our study was to assess (1) the feasibility of point-of-care screening in a primary care clinic and (2) hepatitis B surface antigen (HBsAg) prevalence, associated risk factors, and its clinical and epidemiological implications in undocumented migrants in Brescia, northern Italy. METHODS: A longitudinal prospective study was conducted from January 2006 to April 2010 to assess HBsAg reactivity and associated risk factors among consenting undocumented migrants who accessed the Service of International Medicine of Brescia's Local Health Authority. Genotyping assay was also performed in HBV DNA-positive patients. RESULTS: Screening was accepted by 3,728/4,078 (91.4%) subjects consecutively observed during the study period, 224 (6%) of whom were found to be HBsAg-positive. HBsAg reactivity was independently associated with the prevalence of HBsAg carriers in the geographical area of provenance (p < 0.001). On the contrary, current or past sexual risk behaviors (despite being common in our sample) were not associated with HBV infection. Half of the HBsAg patients (111/224) had either hepatitis B e-antigen (HBeAg)-positive or -negative chronic HBV infection with a possible indication for treatment. HBV genotypes were identified in 45 of 167 HBV-infected patients as follows: genotype D, 27 subjects; genotype A, 8; genotype B, 5; and genotype C, 5. The geographical distribution of genotypes reflected the geographic provenance. CONCLUSIONS: Our results suggest that point-of-care screening is feasible in undocumented migrants and should be targeted according to provenance. Case detection of HBV infection among migrants could potentially reduce HBV incidence in migrants' contacts and in the general population by prompting vaccination of susceptible individuals and care of eligible infected patients

Survival in HIV-Infected Patients after a Cancer Diagnosis in the cART Era: Results of an Italian Multicenter Study

<div><p>Objectives</p><p>We studied survival and associated risk factors in an Italian nationwide cohort of HIV-infected individuals after an AIDS-defining cancer (ADC) or non-AIDS-defining cancer (NADC) diagnosis in the modern cART era.</p><p>Methods</p><p>Multi-center, retrospective, observational study of HIV patients included in the MASTER Italian Cohort with a cancer diagnosis from January 1998 to September 2012. Malignancies were divided into ADC or NADC on the basis of the Centre for Disease Control-1993 classification. Recurrence of cancer and metastases were excluded. Survivals were estimated according to the Kaplan-Meier method and compared according to the log-rank test. Statistically significant variables at univariate analysis were entered in a multivariate Cox regression model.</p><p>Results</p><p>Eight hundred and sixty-six cancer diagnoses were recorded among 13,388 subjects in the MASTER Database after 1998: 435 (51%) were ADCs and 431 (49%) were NADCs. Survival was more favorable after an ADC diagnosis than a NADC diagnosis (10-year survival: 62.7%±2.9% vs. 46%±4.2%; p = 0.017). Non-Hodgkin lymphoma had lower survival rates than patients with Kaposi sarcoma or cervical cancer (10-year survival: 48.2%±4.3% vs. 72.8%±4.0% vs. 78.5%±9.9%; p<0.001). Regarding NADCs, breast cancer showed better survival (10-year survival: 65.1%±14%) than lung cancer (1-year survival: 28%±8.7%), liver cancer (5-year survival: 31.9%±6.4%) or Hodgkin lymphoma (10-year survival: 24.8%±11.2%). Lower CD4+ count and intravenous drug use were significantly associated with decreased survival after ADCs or NADCs diagnosis. Exposure to cART was found to be associated with prolonged survival only in the case of ADCs.</p><p>Conclusions</p><p>cART has improved survival in patients with an ADC diagnosis, whereas the prognosis after a diagnosis of NADCs is poor. Low CD4+ counts and intravenous drug use are risk factors for survival following a diagnosis of ADCs and Hodgkin lymphoma in the NADC group.</p></div