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BACKGROUND: The emergency regarding recent immigration waves into Italy makes continued healthcare monitoring of these populations necessary. METHODS: Through a survey of hospital admissions carried out during the last five years at the S. Orsola-Malpighi General Hospital of Bologna (Italy), all causes of admission of these subjects were evaluated, together with their correlates. Subsequently, we focused on admissions due to infectious diseases. All available data regarding foreign citizens admitted as inpatients or in Day-Hospital settings of our teaching hospital from January 1, 1999, to March 31, 2004, were assessed. Diagnosis-related group (DRG) features, and single discharge diagnoses, were also evaluated, and a further assessment of infectious diseases was subsequently made. RESULTS: Within a comprehensive pool of 339,051 hospitalized patients, foreign citizen discharges numbered 7,312 (2.15%), including 2,542 males (34.8%) and 4,769 females (65.2%). Males had a mean age of 36.8±14.7 years, while females were aged 30.8±12.2 years. In the assessment of the areas of origin, 34.6% of hospitalizations were attributed to patients coming from Eastern Europe, 15.3% from Northern Africa, 7.3% (comprehensively) from Western Europe and United States, 6.9% from the Indian subcontinent, 5.9% from sub-Saharan Africa, 5.7% from Latin America, 4.1% from China, 2.5% from the Philippines, and 1.1% from the Middle East. Among women, most hospitalizations (58.8%) were due to obstetrical-gynecological procedures or diseases, including assistance with delivery (27.1%), and pregnancy complications (18.7%), followed by psycho-social disturbances (5.9%), malignancies (5.1%), gastrointestinal diseases (4.7%), and voluntary pregnancy interruption (4.4%). Among men, the most frequent causes of admissions were related to trauma (15.9%), followed by gastroenteric disorders (12%), heart-vascular diseases (8.9%), psycho-social disorders (8.4%), respiratory (7.1%), kidney (6.1%), liver (5.2%), and metabolic (4.9%) diseases, and alcohol or substance abuse (4.2%). Infectious diseases (alone or with concurrent disorders) were reported in 881 discharged individuals, representing 12.1% of the 7,312 DRGs attributed to foreign patients. The comprehensive patient population discharged from our hospital with at least one infectious disease diagnosis had lower rates of respiratory tract infections, followed by chronic viral hepatitis, HIV infection and related diseases, enterocolitis, pulmonary tuberculosis, pyelonephritis, severe skin and soft tissue infection, meningoencephalitis, and malaria, as the most frequently-reported disorders. CONCLUSIONS: Our survey, through a combined analysis of both DRGs and discharge diagnoses, allowed us to conclude that 12.1% of foreign citizens hospitalized at our General teaching Hospital of Bologna (Italy) suffered from at least one infectious disease. Respiratory tract, liver, and gastrointestinal infections, and HIV infection, were found with an appreciable frequency among discharge diagnoses, while the frequency of malaria and meningoencephalitis was lower, compared with other series. Among disorders other than infectious diseases, obstetric-gynecological conditions and post-traumatic episodes (for male patients) were the most frequent causes of hospitalization.

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The combined therapy with interferon alfa plus ribavirin (INF+RBV) is considered the most appropriate treatment for patients with chronic hepatitis C virus genotypes 2 and 3 in Brazil. However, wide variations in the rates of sustained viral response (SVR) have been reported among such patients. We evaluated, retrospectively, factors associated with SVR in subjects with chronic hepatitis C virus genotypes 2 and 3 and that received medication from the Health Secretariat of the state of São Paulo. One-hundred-seventy-seven consecutive patients with chronic hepatitis C were treated for 24 or 48 weeks according to the viral genotype. Patients co-infected with associated hepatic diseases or who had problems with alcohol abuse were excluded. The genotype of the HCV-RNA was identified through restriction analysis, the viral load through quantitative PCR (Amplicor, Roche) and the degree of hepatic fibrosis according to the Metavir score. Demographic, virological and histological parameters were submitted to binary logistic regression analysis to identify the variables associated with SVR. The overall rate of SVR was 36.4% for the 177 patients, and genotype 2 or 3 was the main parameter independently associated with SVR. Among the 77 patients with these viral genotypes, only the stage of fibrosis had a significant effect on the SVR (odds ratio (OR) = 3.035; 95% CI (confidence interval) = 1.196-7.699; p=0.019). The rate of SVR among the subjects with fibrosis at an advanced stage (F3-F4) was 38%, compared to 75% for patients with fibrosis at an initial stage (F0-F2). Consequently, other therapeutic options should be considered for patients with genotypes 2 and 3 who have advanced fibrosis.

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We assessed the performance of HIV-1 genotyping tests in rescue therapy. Patients were divided into two groups: group 1 (genotyped), included those switching to new antiretroviral drugs based on HIV-1 genotyping data, and group 2 (standard of care -SOC), comprised those in rescue therapy who had not used this test. This was an open and non-randomized study, with 74 patients, followed up for a mean period of 12 months, from February 2002 to May 2003. The groups differed in the duration of antiretroviral use, experience with diverse drug classes (non-nucleoside reverse transcriptase inhibitors and protease inhibitors) and viral load <2.6 log10 copies/mL at any time during treatment. In 23 patients (group 1), the switch in antiretroviral (ARV) regimen was based on genotyping data; this test was not used for 51 patients (group 2). Two CD4 + lymphocyte counts and viral load counts were made for each patient during the study. Data from the pharmacy where patients received antiretroviral agents, medical charts, and direct interviews with patients to assess compliance to treatment, were analyzed. In the genotyped group, the average drop in viral load was 2.8 log10, compared with a 1.5 log10 difference in group 2; the difference was significant in the first assessment performed six months after switching (p=0.001). Considering the patients with viral load < 2.6 log10 (400 copies/mL) after switching, the patients in group 1 had a better performance in the first assessment (73.9% versus 31.1% in groups 1 and 2, respectively); this difference was significant (p=0.001). In multivariate analysis, the variables associated with a greater drop in viral load in the first assessment were the patients whose switching was based on genotyping (group 1), those with a past history of viral load < 2.6 log10 and correct use of antiretroviral agents. In conclusion, the genotyping test and adherence were found to be independent factors for success in the management of patients who failed treatment.

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BACKGROUND: Bacterial pneumonias have been overcoming pneumocytosis in frequency. Controversy still remains about how to manage immunocompromised patients and those with lung diseases. Sputum analysis is a noninvasive and simple method, and when interpreted according to specific criteria it may help with diagnosis. We conducted a study to evaluate sensitivity, specificity, positive and negative predicted values, and the accuracy of induced sputum (IS) for bacterial community-acquired pneumonia diagnosis in HIV-positive patients. MATERIAL AND METHODS: This cross sectional study evaluated a diagnostic procedure in a reference hospital for HIV patients in Florianópolis, SC, Brazil. From January 1, 2001 to September 30, 2002, 547 HIV-positive patients were analyzed and 54 inpatients with pulmonary infection were selected. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were considered the gold standards. Gram stains and quantitative cultures of IS and BAL were obtained. The cut-offs for quantitative cultures were 10(6) CFU/mL for IS and 10(4) CFU/mL for BAL. RESULTS: The mean age was 35.7 years, 79.6% were males and 85.2% were caucasians. The mean lymphocyte count was 124.8/mm³. Bacterial pneumonia was diagnosed in 20 patients. The most prevalent bacteria was Streptococcus pneumoniae. Considering IS for the diagnosis of bacterial pneumonia, sensitivity was 60%, specificity 40%, the positive predictive value was 80%, negative predictive value 20% and accuracy 56%. CONCLUSION: IS with quantitative culture can be helpful for the diagnosis of bacterial pneumonia in HIV-positive patients.

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INTRODUCTION: Amphotericin B (AmphoB) is the drug of choice for treatment of severe fungal illnesses; however, it is very nephrotoxic. Modified (less toxic) amphotericins are very expensive. In low-risk patients, saline loading would be enough to prevent significant loss of renal function. MATERIAL AND METHODS: Patients with normal renal function and within the first 24 hours of treatment with AmphoB were prospectively enrolled in the study. Patients in intensive care units or who were using vasoactive drugs were excluded. Saline loads were infused before and after the AmphoB treatment. Blood and urine analyses were made at the beginning and at the end of the treatment. Serum creatinine was repeated 30 days after the end of the AmphoB treatment. RESULTS: The mean increase in serum creatinine in the 48 patients was 0.3 (0.18-0.41) mg/dL, due to a mean decrease of 25 (12.8-36.9) mL/min of creatinine clearance (CrCl). Acute renal failure, defined as an increase of more than 50% of the baseline creatinine, occurred in 15 patients (31%). Patients that were on antibiotics, in post-chemotherapy status or those submitted to bone marrow transplantation had the highest risk. Mean serum creatinine and the CrCl levels were no different from baseline values after 30 days. CONCLUSION: In low-risk patients, the use of AmphoB with prophylactic sodium chloride loading was associated with a small and reversible decrease in renal function. Due to its high cost the use of more expensive therapies for this type of patient does not seem to be justified.

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Although central vascular catheters (CVC) are indispensable in modern medicine, they are an important risk factor for primary bacteremias. We examined the incidence and risk factors associated with catheter-related bloodstream infection (CR-BSI) caused by Staphylococcus aureus in surgical patients. A prospective study was carried out in the Hospital das Clínicas da Universidade Federal de Uberlândia (HC-UFU) from September 2000 to December 2002. The skin insertion site, catheter tip, and blood were microbiologically analyzed. Demographics and risk factors were recorded for each patient, and cultures were identified phenotypically. Staphylococcus aureus was the most frequent pathogen, with an incidence rate of 4.9 episodes of CR-BSIs per 1,000 catheter/days. Based on logistic regression, the independent risk factors were: colonization on the insertion site =200 colony forming units (CFU)/20 cm² (p=0.03; odds ratio (OR) =6.89) and catheter tip (p=0.01; OR=7.95). The CR-BSI rate was high; it was mainly associated with S. aureus, and skin colonization at the insertion site and on the catheter tip were important risk factors for CR-BSI.

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BACKGROUND: Renal lesions in leprosy have been extensively described, including amyloidosis, glomerulonephritis, nephrosclerosis, tubulointerstitial nephritis and granulomas. MATERIAL AND METHODS: A retrospective study was designed to detect renal function abnormalities in 461 leprosy patients, without any co-morbidity, seen in a university hospital in northeast Brazil. The laboratory test results concerning renal function were examined in the patients' medical records. RESULTS: The mean age was 39 ± 18 years and 217 (47%) were male. The mean duration of disease was 21 ± 38 months. Levels of creatinine above 1.4mg/dL had been detected in 40 patients (8.6%). The levels of creatinine and urea were higher in lepromatous leprosy patients. Proteinuria, hematuria and hemoglobinuria were significantly more frequent in this presentation of leprosy. Nephrotic levels of proteinuria (>3.5mg/dL) were found in three (2.1%) of 138 lepromatous leprosy patients. A positive association was found between duration of disease and high levels of creatinine in the general sample and in the lepromatous leprosy patients. There was no association between time of treatment and high levels of creatinine. CONCLUSION: Renal involvement in leprosy seems to be related to the quantity of bacilli present in the body. It is important to evaluate the renal function in all leprosy patients in order to detect any abnormality and prevent renal failure, which is still a potential cause of death in this disease.

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Early identification of an outbreak is one of the main advantages of routine epidemiological surveillance. Enterococcus spp. used to be regarded as microorganisms of low pathogenicity, because they are part of the normal microbial flora of the gastrointestinal and genitourinary tract. Recently, they have emerged as important pathogenic agents, sometimes causing infections with high mortality rates. We studied a clustering of primary bloodstream infections caused by Enterococcus faecalis in a cardiology hospital neonatal intensive care unit (NICU). Four cases of primary bloodstream infection by E. faecalis were detected from April 15 to May 13, 2004, during active infection surveillance. The isolates were sensitive to glycopeptides. Some aspects of the management of these patients, including the date of insertion and placement of a central venous catheter, prescription of a specific medication, contiguity of beds, personnel attending the patients, and occurrence of diarrhea were analyzed to look for factors that might affect the spread of the microorganisms. Measures taken to hamper the spread included contact precautions throughout the unit, cleansing and disinfection of equipment and surfaces, bathing children with 2% chlorhexidine-gluconate-containing soap, professional reeducation, and reinforcement of all measures to prevent infections. We suggest that there is a need to re-evaluate preventive infection measures and to review the strategies aimed at decreasing the nosocomial infection rate in the NICU.

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Hepatitis C is a worldwide endemic disease, affecting roughly 200 million people. It has a variable prognosis, depending on the progression to fibrosis. During the last five years, the importance of apoptosis for the pathogenesis of various diseases, including hepatitis, has been recognized. It has been suggested that an increase in T cell-apoptosis during a hepatitis C virus infection is the cause of impaired regulation of the immune cellular response, helping to maintain infection. Thus, the interest in discovering the probable mechanisms by which the hepatitis C virus perpetuates in the liver, and to determine the conditions that predispose for progression of this disease, makes investigation of apoptosis in hepatic injury of great interest. We have made an overview of the various mechanisms by which the cell, more specifically the hepatic cell, is affected by apoptosis, and how it interacts with the hepatitis C virus and the immune system.

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Many studies have tried to identify genetic markers for infectious diseases, some of them have focused on human leukocyte antigens (HLA). The products of HLA genes interact with surface-specific receptors of T lymphocytes, resulting in activation of the host's immune response. Association of bacterial, viral, parasitic and fungal infections with the host's HLA has been widely investigated. The type and strength of this association differs among distinct populations, as well as among racial and/or ethnic groups. The new molecular methods for the identification of the HLA alleles, and the resulting new nomenclature, have contributed to a better understanding of this system. Unfortunately, this information has not been adequately transmitted to clinicians, which hampers the understanding of the association between the HLA system and diseases. We revised relevant studies on the association of HLA genes with infectious diseases, demonstrating their importance in the pathogenic mechanisms, through increased susceptibility or protection against infections and their complications.

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Mycophenolate mofetil (MMF) is currently used for prophylaxis of acute rejection in solid organ transplantation. There have been diverging reports regarding an association between MMF and the risk of cytomegalovirus (CMV) infection. We reviewed the main published studies in an attempt to clarify the association between the use of MMF and the risk, frequency and severity of CMV infections. In a search of the Medline database with the terms "mycophenolate" and "cytomegalovir*", 42 articles were found to be relevant; among these, 29 articles were thoroughly analyzed. The first studies on MMF in renal transplantation already showed a tendency towards an association between this drug and the occurrence of CMV disease. Further studies were designed specifically to study this association; with the conclusion that an immunosuppressive regimen containing MMF increases the likelihood of CMV disease. Most studies were performed with kidney transplant recipients. We conclude that the use of MMF apparently increases the incidence of CMV disease in renal transplant patients; however, further studies are needed to confirm this association.

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The HIV epidemic has dramatically changed the paradigm for the development of drug therapy in the last 15 years. The goal is now not only to provide an effective reduction of plasma viremia , but also to reconstitute the immune deficiency due to the progression of the disease. Significant problems with the metabolism of sugars and lipids lead to the appearance of well-documented disorders such as insulin resistance, abnormalities in lipid metabolism and lipodystrophy in those patients on prolonged therapy with antiretrovirals. The question of whether or not HAART-associated lipid disorders contribute to the premature development of coronary artery disease is of major importance for the HIV community. Endothelial injury is associated with disease-related biochemical abnormalities that are implicated in HIV pathogenesis. The exploration of endothelial function began in the early 1980s at the start of the epidemic. The study of endothelial function in HIV infection and its modifications by HAART is an exciting new field in clinical research; in this review the available information on cardiovascular diseases associated with HIV infection and its treatment are discussed.

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Spinal epidural abscess (SEA) is a rare infectious disorder that often has delayed diagnosis and is associated with significant morbidity and mortality rates. We present a case of an AIDS patient with a SEA due to Mycobacterium tuberculosis. This type of SEA in AIDS patients is characterized by localized spinal pain and prolonged fever. Magnetic resonance imaging is the method of choice in the diagnostic process. Early diagnosis, followed by specific therapy (surgical decompression combined with antituberculous drugs), is necessary to improve the prognosis of these kinds of patients.

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We describe a case of a male patient, 38 years old, HIV-positive (most recent CD4 count about 259/mm³), with abdominal pain, nausea, vomiting, anorexia, weight loss, and vespertine high fever with chills. His hemogram showed normocytic and normochromic anemia, with a high erythrocyte sedimentation rate (ESR) and gross granulations in the neutrophils. Transaminases were normal. Bone marrow biopsy evidenced a chronic disease anemia pattern and a lack of infectious agents. Abdominal ultrasound examination showed a normal-size spleen, which exhibited heterogeneous parenchyma and multiple small hypoechoic images, together with small ascites, peripancreatic and para-aortic lymphadenopathy. These findings were confirmed by abdominal CT. The liver was normal in size, but had a hyperechoic image, which was not visualized on CT. Histopathological analysis of one of the multiple abdominal lymph nodes obtained by laparoscopic biopsy exhibited a chronic granulomatous inflammatory process, with caseous necrosis. Tissue sections were positive for BAAR (acid-alcohol-resistant bacillus), and the cultures were positive for Mycobacterium tuberculosis. Anti-tuberculosis treatment was begun, and the patient evolved with improvement of his general state, fever remission and weight gain. Splenic tuberculosis is a rare disease, occurring predominantly in patients in late stages of AIDS and/or disseminated tuberculosis. It is a difficult diagnosis, since there are no specific findings. Hence, complementary examinations, such as abdominal ultrasound/ CT, or fine needle aspiration, are usually necessary for investigation and differential diagnosis. Often, lesion regression after anti-tuberculosis regimens can be seen, and splenectomy is restricted to complicated or refractory disease.

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We report the isolation of Neisseria meningitidis, characterized as B:NT:P1.7, from a female patient's genital tract in an outpatient clinic for HIV care. The gynecology clinic, as part of the follow up, collects specimens from all patients with HIV infection for routine exams and for early laboratory detection of sexually transmitted diseases . A Gram-negative diplococcus was isolated from the cervix of a heterosexual patient with AIDS. Based on this and other reported cases, urogenital infection with N. meningitidis can no longer be considered uncommon. The rising incidence of N. meningitidis isolated from this and similar sites has significant medical and diagnostic implications.

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We examined varicella transmission in a hospital specialized in cancer treatment. A cases series study was made of a case of intra-hospital transmission of varicella, based on a revision of the records of patients who had been admitted during the time the index case was in the same service. Records of interviews of employees were also reviewed. During the period that the index case was in the intensive care unit, 34 patients were admitted and 35 employees worked there. Two employees and a patient developed the illness, due to transmission directly or indirectly from the index case. Although this is a service in which most of the patients are adults who have cancer, attention needs to be directed towards diagnosis and to procedures to reduce the transmission of this illness, both to healthcare professionals, and to other patients. A standard schedule for varicella prevention already exists; however, this case reinforces the need for specific vaccination of at-risk professionals.