Publications by authors named "Maria Musso"

16 Publications

  • Page 1 of 1

Risk and predictive factors of prolonged viral RNA shedding in upper respiratory specimens in a large cohort of COVID-19 patients admitted to an Italian reference hospital.

Int J Infect Dis 2021 Apr 3;105:532-539. Epub 2021 Mar 3.

National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy.

Background: Limited data are available about the predictors and outcomes associated with prolonged SARS-CoV-2 RNA shedding (VS).

Methods: A retrospective study including COVID-19 patients admitted to an Italian hospital between March 1 and July 1, 2020. Predictors of viral clearance (VC) and prolonged VS from the upper respiratory tract were assessed by Poisson regression and logistic regression analyses. The causal relation between VS and clinical outcomes was evaluated through an inverse probability weighted Cox model.

Results: The study included 536 subjects. The median duration of VS from symptoms onset was 18 days. The estimated 30-day probability of VC was 70.2%. Patients with comorbidities, lymphopenia at hospital admission, or moderate/severe respiratory disease had a lower chance of VC. The development of moderate/severe respiratory failure, delayed hospital admission after symptoms onset, baseline comorbidities, or D-dimer >1000ng/mL at admission independently predicted prolonged VS. The achievement of VC doubled the chance of clinical recovery and reduced the probability of death/mechanical ventilation.

Conclusions: Respiratory disease severity, comorbidities, delayed hospital admission and inflammatory markers negatively predicted VC, which resulted to be associated with better clinical outcomes. These findings highlight the importance of prompt hospitalization of symptomatic patients, especially where signs of severity or comorbidities are present.
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http://dx.doi.org/10.1016/j.ijid.2021.02.117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927669PMC
April 2021

Dermatological manifestations during COVID-19 and histological picture: Description of two clinical cases.

J Dermatol 2021 May 23;48(5):651-656. Epub 2021 Feb 23.

Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy.

It is not yet entirely clear what is the relevance of skin symptoms and what clinical implications are related to their appearance in COVID-19 patients. We describe two cases of COVID-19-associated pneumonia, which presented skin manifestations in advanced stage of illness, when nasopharyngeal swabs became negative for SARS-CoV-2. The first case presented erythematous, maculopapular lesions; the second developed petechial, vesicular and blood-encrusted lesions on the limbs. Histopathology documented perivascular lymphocytic infiltrates, with prevalent CD4+ T-cells in both patients. The research of SARS-CoV-2 in tissues with real time RT-PCR was negative. Basal keratinocytes displayed C4d deposits in one case, who developed laboratory signs indicative of a procoagulative condition at the same time as the skin rash. Skin manifestations during SARS-CoV-2 infection seem to be clinically relevant and further studies are necessary to assess if they are linked to systemic complications, lack of viral clearance or cascades of immune responses induced by the virus, even in patients affected by mild pneumonia.
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http://dx.doi.org/10.1111/1346-8138.15714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013512PMC
May 2021

Concurrent cavitary pulmonary tuberculosis and COVID-19 pneumonia with in vitro immune cell anergy.

Infection 2021 Jan 17. Epub 2021 Jan 17.

Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy.

Tuberculosis (TB) is top infectious disease killer caused by a single organism responsible for 1.5 million deaths in 2018. Both COVID-19 and the pandemic response are risking to affect control measures for TB and continuity of essential services for people affected by this infection in western countries and even more in developing countries. Knowledge about concomitant pulmonary TB and COVID-19 is extremely limited. The double burden of these two diseases can have devastating effects. Here, we describe from both the clinical and the immunological point of view a case of a patient with in vitro immune cell anergy affected by bilateral cavitary pulmonary TB and subsequent COVID-19-associated pneumonia with a worst outcome. COVID-19 can be a precipitating factor in TB respiratory failure and, during ongoing SARS-COV-2 pandemic, clinicians must be aware of this possible co-infection in differential diagnosis of patients with active TB and new or worsening chest imaging.
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http://dx.doi.org/10.1007/s15010-021-01576-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811686PMC
January 2021

Heparin in COVID-19 Patients Is Associated with Reduced In-Hospital Mortality: the Multicenter Italian CORIST Study.

Thromb Haemost 2021 Jan 7. Epub 2021 Jan 7.

Cardiovascular and Thoracic Department, Azienda Ospedaliero-Universitaria Pisana and University of Pisa, Pisa, Italy.

Introduction:  A hypercoagulable condition was described in patients with coronavirus disease 2019 (COVID-19) and proposed as a possible pathogenic mechanism contributing to disease progression and lethality.

Aim:  We evaluated if in-hospital administration of heparin improved survival in a large cohort of Italian COVID-19 patients.

Methods:  In a retrospective observational study, 2,574 unselected patients hospitalized in 30 clinical centers in Italy from February 19, 2020 to June 5, 2020 with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection were analyzed. The primary endpoint in a time-to event analysis was in-hospital death, comparing patients who received heparin (low-molecular-weight heparin [LMWH] or unfractionated heparin [UFH]) with patients who did not. We used multivariable Cox proportional-hazards regression models with inverse probability for treatment weighting by propensity scores.

Results:  Out of 2,574 COVID-19 patients, 70.1% received heparin. LMWH was largely the most used formulation (99.5%). Death rates for patients receiving heparin or not were 7.4 and 14.0 per 1,000 person-days, respectively. After adjustment for propensity scores, we found a 40% lower risk of death in patients receiving heparin (hazard ratio = 0.60; 95% confidence interval: 0.49-0.74; E-value = 2.04). This association was particularly evident in patients with a higher severity of disease or strong coagulation activation.

Conclusion:  In-hospital heparin treatment was associated with a lower mortality, particularly in severely ill COVID-19 patients and in those with strong coagulation activation. The results from randomized clinical trials are eagerly awaited to provide clear-cut recommendations.
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http://dx.doi.org/10.1055/a-1347-6070DOI Listing
January 2021

Common cardiovascular risk factors and in-hospital mortality in 3,894 patients with COVID-19: survival analysis and machine learning-based findings from the multicentre Italian CORIST Study.

Nutr Metab Cardiovasc Dis 2020 10 31;30(11):1899-1913. Epub 2020 Jul 31.

UOC Malattie Infettive, Ospedale San Gerardo, ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.

Background And Aims: There is poor knowledge on characteristics, comorbidities and laboratory measures associated with risk for adverse outcomes and in-hospital mortality in European Countries. We aimed at identifying baseline characteristics predisposing COVID-19 patients to in-hospital death.

Methods And Results: Retrospective observational study on 3894 patients with SARS-CoV-2 infection hospitalized from February 19th to May 23rd, 2020 and recruited in 30 clinical centres distributed throughout Italy. Machine learning (random forest)-based and Cox survival analysis. 61.7% of participants were men (median age 67 years), followed up for a median of 13 days. In-hospital mortality exhibited a geographical gradient, Northern Italian regions featuring more than twofold higher death rates as compared to Central/Southern areas (15.6% vs 6.4%, respectively). Machine learning analysis revealed that the most important features in death classification were impaired renal function, elevated C reactive protein and advanced age. These findings were confirmed by multivariable Cox survival analysis (hazard ratio (HR): 8.2; 95% confidence interval (CI) 4.6-14.7 for age ≥85 vs 18-44 y); HR = 4.7; 2.9-7.7 for estimated glomerular filtration rate levels <15 vs ≥ 90 mL/min/1.73 m; HR = 2.3; 1.5-3.6 for C-reactive protein levels ≥10 vs ≤ 3 mg/L). No relation was found with obesity, tobacco use, cardiovascular disease and related-comorbidities. The associations between these variables and mortality were substantially homogenous across all sub-groups analyses.

Conclusions: Impaired renal function, elevated C-reactive protein and advanced age were major predictors of in-hospital death in a large cohort of unselected patients with COVID-19, admitted to 30 different clinical centres all over Italy.
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http://dx.doi.org/10.1016/j.numecd.2020.07.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833278PMC
October 2020

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital.

Antibiotics (Basel) 2020 Aug 7;9(8). Epub 2020 Aug 7.

Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, 00149 Rome, Italy.

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12-3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08-2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08-1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13-1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.
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http://dx.doi.org/10.3390/antibiotics9080489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459440PMC
August 2020

Usefulness of bronchoalveolar lavage in the management of patients presenting with lung infiltrates and suspect COVID-19-associated pneumonia: A case report.

Int J Infect Dis 2020 Aug 11;97:174-176. Epub 2020 May 11.

National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy. Electronic address:

Objective: To report a clinical case of a patient with a compatible HRCT scan and two negative SARS-CoV-2 RNA upper respiratory tract specimens but with a confirmed viral infection by BAL (19 days after symptom onset).

Methods: Revision of a patient's clinical charts with COVID-19 admitted at INMI L. Spallanzani Hospital RESULTS: Two oropharyngeal swab tests of SARS-CoV-2 by qualitative real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay were performed at admission (17 days from symptoms onset) and a day apart and were found negative. BAL fluid collected 19 days after symptoms onset was positive for SARS-CoV-2.

Conclusion: This case highlights importance of clinical suspicion of SARS-CoV-2 infection in diagnosis and infectivity assessment. We suggest collection of BAL fluid when consecutive nasopharyngeal swabs are negative, to confirm or exclude the diagnosis of COVID-19-associated pneumonia. Healthcare workers should perform aerosol-generating procedures in an adequately ventilated room and should wear adequate PPE.
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http://dx.doi.org/10.1016/j.ijid.2020.05.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211646PMC
August 2020

Hepatitis C virus infection: a challenge in the complex management of two cases of multidrug-resistant tuberculosis.

BMC Infect Dis 2019 Oct 22;19(1):882. Epub 2019 Oct 22.

Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy.

Background: Multidrug-resistant tuberculosis (MDR-TB) requires lengthy use of second-line drugs, burdened by many side effects. Hepatitis C virus (HCV) chronic infection increases risk of drug-induced liver injury (DILI) in these patients. Data on MDR-TB patients with concurrent HCV chronic infection treated at the same time with second-line antitubercular drugs and new direct-acting antivirals (DAAs) are lacking. We evaluate if treating at the same time HCV infection and pulmonary MDR-TB is feasible and effective.

Cases Presentation: In this study, we described two cases of patients with pulmonary MDR-TB and concurrent HCV chronic infection cured with DAAs at a Tertiary Infectious Diseases Hospital in Italy. During antitubercular treatment, both patients experienced a DILI before treating HCV infection. After DAAs liver enzymes normalized and HCV RNA was undetectable. Then antitubercular regimen was started according to the institutional protocol, drawn up following WHO MDR-TB guidelines. It was completed without further liver side effects and patients were declared cured from both HCV infection and MDR-TB.

Conclusions: We suggest to consider treatment of chronic hepatitis C with DAAs as a useful intervention for reintroduction of second-line antitubercular agents in those patients who developed DILI, reducing the risk of treatment interruption when re-exposed to these drugs.
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http://dx.doi.org/10.1186/s12879-019-4494-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806539PMC
October 2019

Putting in harm to cure: Drug related adverse events do not affect outcome of patients receiving treatment for multidrug-resistant Tuberculosis. Experience from a tertiary hospital in Italy.

PLoS One 2019 28;14(2):e0212948. Epub 2019 Feb 28.

Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy.

Rationale: Treatment of multi-drug resistant Tuberculosis (MDR-TB) is challenging because it mostly relies on drugs with lower efficacy and greater toxicity than those used for drug-susceptible TB.

Objectives: Aim of the study was to describe the frequency and type of adverse drug reactions in a cohort of MDR-TB patients and their potential impact on treatment outcome.

Methods: We conducted a retrospective study in a cohort of MDR-TB patients enrolled at a tertiary referral hospital in Italy from January 2008 to December 2016. The records of patients were reviewed for epidemiological, clinical, microbiological and adverse drug reactions data.

Results: Seventy-four MDR-TB patients (mean age 32 years, 58.1% males, 2 XDR, 12 pre-XDR TB) were extracted from the Institute data base and included in the retrospective study cohort in the evaluation period (January 2008-December 2016). Median length of treatment duration was 20 months (IQR 14-24). Treatment outcome was successful in 57 patients (77%; 51 cured, 6 treatment completed); one patient died and one failed (2.7% overall); 15 patients were lost to follow-up (20.3%). Sixty-six (89.2%) presented adverse drug reactions during the whole treatment period. Total number of adverse drug reactions registered was 409. Three hundred forty-six (84.6%) were classified as adverse events (AEs) and 63 (15.4%) were serious AEs (SAEs). One third of the total adverse drug reactions (134/409; 32.8%) was of gastrointestinal origin, followed by 47/409 (11.5%) ototoxic drug reactions, thirty-five (8.6%) regarded central nervous system and 33 (8.1%) affected the liver. All 63 SAEs required treatment suspension with 61 SAEs out of 63 (96.8%) occurring during the first six months of treatment. Factors associated with unsuccessful treatment outcome were smoking (p = 0.039), alcohol abuse (p = 0.005) and homeless condition (p = 0.044). Neither the number of antitubercular drugs used in different combinations nor the number of AEs showed significant impact on outcome. Patients who completed the treatment experienced a greater number of AEs and SAEs (p < 0.001) if compared to lost to follow-up patients.

Conclusions: Our data demonstrate that, despite the high frequency of adverse drug reactions and long term therapy, the clinical management of MDR-TB patients in a referral center could reach successful treatment according to WHO target, by implementing active and systematic clinical and laboratory assessment to detect, report and manage suspected and confirmed adverse drug reactions.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212948PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394924PMC
November 2019

Persistent detection of dengue virus RNA in vaginal secretion of a woman returning from Sri Lanka to Italy, April 2017.

Euro Surveill 2017 Aug;22(34)

National Institute for Infectious Diseases 'Lazzaro Spallanzani', IRCCS, Rome, Italy.

We describe the dynamics of dengue virus (DENV) infection in a woman in her mid-30s who developed fever after returning from Sri Lanka to Italy in April 2017. Laboratory testing demonstrated detectable DENV-RNA in plasma, urine, saliva, vaginal secretion. Persistent shedding of DENV-RNA was demonstrated in vaginal secretion, and DENV-RNA was detectable in the pelleted fraction up to 18 days from symptom onset. These findings give new insights into DENV vaginal shedding and vertical transmission.
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http://dx.doi.org/10.2807/1560-7917.ES.2017.22.34.30600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753441PMC
August 2017

Nuclear medicine in diagnosis of prosthetic valve endocarditis: an update.

Biomed Res Int 2015 28;2015:127325. Epub 2015 Jan 28.

National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Via Portuense 292, 00149 Rome, Italy.

Over the past decades cardiovascular disease management has been substantially improved by the increasing introduction of medical devices as prosthetic valves. The yearly rate of infective endocarditis (IE) in patient with a prosthetic valve is approximately 3 cases per 1,000 patients. The fatality rate of prosthetic valve endocarditis (PVE) remains stable over the years, in part due to the aging of the population. The diagnostic value of echocardiography in diagnosis is operator-dependent and its sensitivity can decrease in presence of intracardiac devices and valvular prosthesis. The modified Duke criteria are considered the gold standard for diagnosing IE; their sensibility is 80%, but in clinical practice their diagnostic accuracy in PVE is lower, resulting inconclusively in nearly 30% of cases. In the last years, these new imaging modalities have gained an increasing attention because they make it possible to diagnose an IE earlier than the structural alterations occurring. Several studies have been conducted in order to assess the diagnostic accuracy of various nuclear medicine techniques in diagnosis of PVE. We performed a review of the literature to assess the available evidence on the role of nuclear medicine techniques in the diagnosis of PVE.
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http://dx.doi.org/10.1155/2015/127325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324115PMC
November 2015

Invasive Candidiasis due to Candida Norvegensis in a Liver Transplant Patient: Case Report and Literature Review.

Infect Dis Rep 2014 May 24;6(2):5374. Epub 2014 Jun 24.

Second Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani , Rome.

Candida norvegensis is an emerging fluconazole-resistant pathogen isolated in most cases from skin and mucous membranes of immunocompromized patients. Documented invasive candidiasis (IC) due to C. norvegensis has been rarely reported, thus the clinical features of patients at risk for this pathogen are poorly defined. We report a liver transplant patient who developed IC due to C. norvegensis and review other cases of C. norvegensis IC published in the literature.
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http://dx.doi.org/10.4081/idr.2014.5374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083299PMC
May 2014

Extra-cerebral severe infections associated with haemorrhagic hereditary telangiectasia (Rendu-Osler-Weber Disease): five cases and a review of the literature.

Infez Med 2014 Mar;22(1):50-6

Second Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy.

Hereditary haemorrhagic telangiectasia (HHT) is one of the most common autosomal dominant disorders and is characterized by genetically determined abnormalities of vascular structure. People affected by HHT are predisposed to severe infections such as cerebral abscesses, typical of patients with pulmonary arteriovenous malformations, and extra-cerebral infections such as bacteraemia, septic arthritis, osteomyelitis, hepatic abscesses, skin infections and infective endocarditis. We present a retrospective series of severe bacterial extra-cerebral infections in five patients affected by HHT, admitted to our Institute from January 2007 to June 2013. We also reviewed the literature of the last five years concerning infectious complications in people affected by HHT. Our study shows that HHT patients with infectious complications exclusively localized in extra-cerebral sites are usually fragile, old and affected by comorbidities. Moreover, we recognized a trend of Staphylococcus aureus (SA) severe infection recurrence in such patients, both in our series and in the literature. In our opinion these results suggest the need to evaluate the possible benefits of SA nasal colonization screening and decolonization in such patients.
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March 2014

Clostridium difficile infection in the elderly.

Infez Med 2013 Jun;21(2):93-102

National Institute for Infectious Diseases L. Spallanzani, Rome, Italy.

The incidence of C. difficile infections (CDI) in the elderly continues to rise and infection is associated with increased morbidity and mortality when compared to those affected in younger age-groups. Immunosenescence may be a contributory factor yet the exact immune responses that may protect against CDI are incompletely understood. Increased exposure to antibiotics, frequent and/or prolonged hospital admissions and residing in long-term care facilities provide multiple opportunities for host and pathogen to coincide. This review explores the epidemiology, diagnostic parameters and management of the spectrum of disease in the geriatric population. Deaths attributed to CDI are most common in the elderly population and are a major contributor to gastroenteritis-associated mortality in many countries. The elderly represent an at-risk population from this pathogen and efforts must be directed to preventing infection and optimising treatment in this group.
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June 2013

Clostridium difficile infection in Italian urban hospitals: data from 2006 through 2011.

BMC Infect Dis 2013 Mar 22;13:146. Epub 2013 Mar 22.

Background: In developed countries, Clostridium difficile infection (CDI) represents an emerging threat in terms of morbidity and mortality rates. In our country limited CDI epidemiological data can be found.

Methods: Stool samples tested for C. difficile toxins from January 2006 to December 2011 in 5 large hospitals in Rome, Italy, were considered in the analysis. Repeated samples taken ≤ 2 months after a positive result were excluded.

Results: A total of 402 CDI episodes were identified. The incidence of CDI episodes progressively increased from 0.3 in 2006 to 2.3 per 10,000 patient-days in 2011. CDI episodes mostly occurred in patients > 60 years of age (77%). The >80 year-old age class reported the highest percentage of CDI episodes on tested samples (16%). Eighty percent (80%) of CDI episodes occurred in medical wards followed by surgery (10.2%) and intensive care units (9.8%).

Conclusions: A significant increasing incidence of CDI episodes over the study period was observed during the years (p<.001), particularly in the older age groups. Medical wards experienced the highest number of CDI episodes as compared to intensive care and surgical wards. The increasing rate of CDI episodes over the last six years in our country, is alarming; urgent improvements in the surveillance systems and control programs are advisable.
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http://dx.doi.org/10.1186/1471-2334-13-146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3614456PMC
March 2013

Salmonella enterica ssp. arizonae infection in a 43-year-old Italian man with hypoglobulinemia: a case report and review of the literature.

J Med Case Rep 2011 Jul 22;5:323. Epub 2011 Jul 22.

Second Infectious Diseases Division, National Institute for Infectious Diseases, 'Lazzaro Spallanzani', Via Portuense, 292 00149, Rome, Italy.

Introduction: Salmonella enterica ssp. arizonae is an uncommon human pathogen with serious infections reported in immunocompromised hosts. In Europe, only a few cases have been described. Patients with this infection usually have a history of contact with reptiles or travel abroad. We present a case report of infection in a patient with hypoglobulinemia and a literature review.

Case Presentation: We describe the case of a 43-year-old Caucasian Italian man with hypoglobulinemia who presented to our hospital with sepsis and diarrhea. A stool culture yielded S. enterica ssp. arizonae. Our patient was treated with oral ciprofloxacin and made a full recovery. We also present a review of the cases of S. enterica ssp. arizonae infections previously reported in Europe.

Conclusions: The majority of infections from S. enterica ssp. arizonae occur in patients who are immunocompromised. Data from the literature suggests that it may be difficult to eradicate the bacteria and thus, prolonged antibiotic courses are often used. It would be advisable for clinicians to investigate for pre-existing immune dysfunction if S. enterica ssp. arizonae is isolated. In Italy, although there have only been a few cases, the likely route of transmission remains unclear and requires further surveillance.
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http://dx.doi.org/10.1186/1752-1947-5-323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156765PMC
July 2011