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A unique case of severe measles complicated by multiple features of gas accumulation is described, on the ground of the available literature evidences. Complications from measles have been reported in every organ system and they may vary by age and underlying conditions. Pneumomediastinum is usually associated with subcutaneous emphysema and pneumopericardium, but rarely associated with pneumothorax. We report extremely rare simultaneous occurrence of self-limiting pneumomediastinum, pneumopericardium, subcutaneous neck and chest region emphysema, and pneumothorax, in a 19-year-old girl with measles. A review of the literature has documented only one previous report of spontaneous pneumomediastinum, subcutaneous emphysema and pneumothorax in the course of measles, and no previous cases reported the association of pneumomediastinum, subcutaneous emphysema, pneumopericardium and pneumothorax complicating measles.

Two recent cases of extremely severe thrombocytopenic purpura related to a concomitant cytomegalovirus infection, either associated or not with an underlying immunosuppression, draw our attention on this intriguing pathologic association, on the ground of an updated literature review.

An intriguing case of lethal rickettsiosis caused by Rickettsia conorii complicated by brain involvement and the presence anti-phospholipid antibodies is presented and discussed, on the ground of recent literature evidences.

Introduction: Both natural history and epidemiological trend of HIV infection have been deeply modified by the introduction of highly active antiretroviral therapy (HAART), around twenty years ago., Methods: However, despite a rapid drop of the incidence of the large majority of opportunistic infections, a slow, but continued increase of malignancies occurred, with particular evidence focused on cancers which are not strictly related to the definition of full blown AIDS (the so called non-AIDS-defining malignancies)., Results: The unique clinical occurrence of HIV infection complicated by even four non-AIDS-defining cancers prompted us to re-discuss the epidemiology and the possible pathogenesis, the clinical presentation, and the differential diagnosis of this pathologic presentation., Conclusions: On the ground of our experience in this field, and the available literature evidences, we discuss how this clinical occurrence is acting on HIV infection presentation during the HAART era of the third millennium. These changes need broad scale studies, and promise relevant consequences on etiopathogenetic, prevention, therapeutic, and management aspects of HIV disease in the next future.

The beginning of the third millennium has been characterized by the emerging and progressive characterization of a novel malaria Plasmodium pathogen of simian origin (Plasmodium knowlesi), which now represents the fifth human malaria parasite. Evolutionary, environmental, and diagnostic-clinical features are briefly outlined on the ground of the most recent literature evidences.

The epidemiological figures regarding malignancies not included in the current definition of full-blown AIDS are presented, as prospectively recorded at our Centre since the year 2000. The diagnostic and clinical implications are discussed on the ground of the most recent literature evidences.

The most recent evidences on HIV infection have been obtained through large multicentre trials, or intercohort analyses including patients enrolled by hundreds of investigators-coinvestigators around the world. While extensively pooled data are needed to assess infrequent events (proportionally rare toxicity), long-term end-points (like mortality), or to perform efficacy or non-inferiority comparisons between different therapeutic strategies, relevant biases-distorsions descending from the extremely elevated number of enrolling centers and sperimentators are expected, while the full report among quoted co-authors of all investigators and co-investigators supports an unacceptable number of presumptive authors of each paper, ranging from hundreds to over one thousand.

The introduction of novel, fixed nucleoside-nucleotide reverse transcriptase inhibitor (NRTI) combinations (tenofovir-emtricitabine, and abacavir-lamivudine), expanded the spectrum of available formulations and increased patient's adherence. A prospective survey of the open-label use of these two fixed combinations was performed in 158 patients belonging to our single-centre cohort of over 1,000 HIV-infected subjects enrolled in the last 18 months, and followed for at least 12 months. During the last 18 months, 95 consecutive, evaluable patients (60.1%) received for the first time tenofovir-emtricitabine, or abacavir-lamivudine (63 patients, 39.9%), and were followed for at least 12 months. A major role seems to be played by tenofovir-emtricitabine in first-line treatments (preferably among "compact" regimens based on efavirenz), while the proportionally increased abacavir-lamivudine prescription to pre-treated patients is mostly attributable to the different genetic barrier of abacavir (often associated with boosted protease inhibitors, in this last patient group). The present availability to two more fixed NRTI combinations favored by their single pill, once-daily administration encourages randomized, controlled "head to head" studies in both first-line and experienced patients, in order to better exploit and target their therapeutic potential.

Multi-antibiotic resistant Gram-positive cocci represent emerging pathogens especially in the setting of the immunocompromised, hospitalized patients, in particular when surgery, invasive procedures, or prosthetic implants are of concern, patients are admitted in intensive care units, or underlying chronic disorders and immunodeficiency are of concern, and broad-spectrum antibiotics and/or immunosuppressive drugs are widely administered. The spectrum of available antimicrobial compounds for an effective management of these relevant infections is significantly impaired in selection and clinical efficacy by the emerging and spread of methicillin-resistant and more recently glycopeptide-resistant Gram-positive microbial strains linezolid, together with the recently licensed quinupristin-dalfopristin, daptomycin and tigecycline, followed by a number of glycopeptides, fluoroquinolones, and other experimental compounds represent an effective response to these concerns, due to their innovative mechanisms of action, their maintained or enhanced activity against multiresistant pathogens, their effective pharmacokinetic/pharmacodynamic properties, their frequent possibility of synergistic activity with other compounds effective against Gram-positive pathogens, and a diffuse potential for a safe and easy administration, also when compromised patients are of concern. The main problems related to the epidemiological and clinical features of multiresistant Gram-positive infection, the potential clinical indications of all recently available compounds compared with the standard of treatment of resistant Gram-positive infections, and updated data on efficacy and tolerability of linezolid have to be clarified.

Highly active antiretroviral therapy (HAART) has had a significant impact on the natural history of human immunodeficiency virus (HIV) infection, leading to a remarkable decrease in its morbidity and mortality, but is frequently associated with clinical and metabolic complications. Fat redistribution syndrome or lipodystrophy, hyperlipidaemia, insulin resistance and diabetes have been extensively reported in subjects treated with new, potent antiretroviral regimens. The potential long-term consequences of HAART-associated metabolic alterations are not completely understood, but an increased risk of premature coronary artery disease has been reported in young HIV-positive persons receiving HAART. On the other hand, the use of potent and expensive antiretroviral combinations in developing countries is very restricted and is unlikely to slow the AIDS pandemic, leading to a desperate need for a vaccine. Despite 20 years of effort, it is still a long way off, even also considerable progress has been made in understanding this problem.

It is reported on the ground of the most updated literature evidences an infrequent case of multiple cavitating pulmonary infiltrates and a probable liver abscess caused by a Nocardia asteroides disseminated infection heralding a HIV-related profound immunodeficiency who remained missed and undiagnosed until the emerging of this severe opportunistic infection.

Patients and Methods: In a three-year prospective survey of 135 consecutive adult patients referred for fever of unknown origin often associated with a broad spectrum of constitutional signs and symptoms, 21 (15.5%) were found to have a primary Cytomegalovirus infection., Results: In the majority of cases, this syndrome was consistently associated with altered white blood cell count, abnormal T-lymphocyte subsets and hepatosplenomegaly. On the other hand, altered white blood cell differential and serum hepatic enzymes, and constitutional signs and symptoms were absent with a rate ranging from 11.1% to 27.4% of cases, and an initial laboratory cross-reaction with anti-Epstein-Barr IgM antibodies was detected in 48.1% of episodes. Non-specific signs and symptoms were the only features in 27.4% of patients, thus confirming that this disorder may be still clinically underestimated in its real frequency, until virologic assays are carried out. An extensive and varied spectrum of subjective disturbances, sometimes of duration prolonged beyond six months involved nearly 30% of subjects, and lasted for 3-15 months after recovery of acute, primary Cytomegalovirus disease., Conclusions: In a multidisciplinary (clinical, laboratory, and instrumental) workup for a fever of unknown origin, a rapid recognition of a primary Cytomegalovirus disease is useful to exclude alternative diagnoses, avoid unnecessary exposure to antimicrobial agents, and reassure patients of the benign and self-limiting course of their illness.

During the last months of 2003, outbreaks of avian flu caused by influenza A (H5N1) virus were described in eight Asian countries, and has paralleled an epidemic of human influenza caused by the same avian virus A (H5N1). Between December 26, 2003 and October 13, 2005, there had been 117 documented human infections and 60 deaths (mortality, 51%) in four Asian countries: Vietnam, Thailand, Cambodia and Indonesia. Human influenza sustained by H5N1 virus is usually characterized by a severe lower respiratory tract infection, leading to a progressive respiratory failure and several extra-respiratory complications. Infected birds have been the primary source of influenza H5N1 infection in humans in Asia, but transmission from poultry to humans is very limited at present, and requires a direct exposure to live birds, whereas there was no significant risk related to eating well-cooked poultry meat. Human-to-human transmission of H5N1 virus has been suggested in several household clusters, but it seems very uncommon at present. All the viral genes of human H5N1 isolates were of avian influenza origin, which indicates absence of reassortment with human influenza viruses, but H5N1 continue to evolve and persistent monitoring is requested to identify any increase in viral adaptation to man, which could lead to a human pandemic.

A preliminary open-label study on the administration of the novel, parenteral HIV fusion inhibitor enfuvirtide as a part of a salvage antiretroviral treatment in a cohort of hardly pretreated and multiresistant patients with advanced HIV disease followed until 30 consecutive months of therapy is presented, and discussed on the ground of available experiences, and an update of literature evidences in this field. Expectations and concerns on the use of this novel anti-HIV compound (belonging to an innovative pharmacological class) in daily practice are debated, since no specific recommendations have been produced until now, and enfuvirtide administration appears significantly more effective when made in conjunction with at least one or two other active antiretroviral agents. The management of the very frequent site injection reactions represents an adjunctive problem in the treatment of these multi-problematic patients.

A four-year retrospective survey was carried out at our Infectious Disease ward, to point out discrepancies between immediately hospitalized patients, and those referred to us for admission, but needing trasferral elsewhere, due to lack of a suitable room. Since the year 2000, 439 patients out of 1979 (28.5%) could not find a place at our ward. Paralleling increased rooms at our ward in June 2002 (16 to 35 beds), the described phenomenon had a sharp drop, but a subsequent stabilization followed, with around 13% of Infectious Disease patients sent elsewhere for hospitalization until July 2003. Patients with severe, transmissible diseases are of particular concern, when the accepting Infectious Disease unit is located 40-115 km far from our city. This occurrence happened in nearly 25% of patients trasferred from our Hospital from the year 2000.

Ticks are obligate, blood-sucking ectoparasites that are the most common agents of vector-borne infectious disease in the United States and European countries. Ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites, and tick bites cause a variety of acute and chronic infectious diseases, including Lyme disease, tick-borne relapsing fever, Rocky Mountain and Mediterranean spotted fevers, ehrlichiosis, Q fever, tularemia, babesiosis, and tick-borne viral encephalitis. Since its identification nearly 30 years ago, Lyme disease has continued to spread, and it is now the most commonly reported arthropod-borne illness in American and European countries. Rickettsial infections are widely distributed throughout the world and have a remarkable influence on public health and military activities as a possible biological weapon. Tick-borne encephalitis virus is endemic in central, eastern and northern Europe and may cause a wide spectrum of clinical forms, ranging from asymptomatic infection to severe meningo-encephalitis. This article reviews the epidemiology, microbiology, clinical manifestation, diagnosis and treatment of the major tick-borne infectious diseases in the United States and Europe.

A wide range of morphologic alterations and lipid metabolism abnormalities have been recently described in HIV-infected patients receiving a protease inhibitor-based highly active antiretroviral therapy. The hyperlipidaemia may involve up to 70-80% of HIV-positive subjects treated with a protease inhibitor-containing regimen, and it is frequently (but not always) associated with the fat redistribution syndrome or lipodystrophy. The potential clinico-pathological consequences of HIV-associated hyperlipidaemia are not completely known, but several anecdotal observations reported an increased risk of prematury coronary artery diseases in young HIV-positive individuals receiving protease inhibitors, besides peripheral atherosclerosis and acute pancreatitis. A hypolipidaemic diet and regular physical exercise may act favourably on dyslipidaemia, but pharmacological therapy becomes necessary when hyperlipidaemia is severe or pesists for a long time. The choice of hypolipidaemic drugs is problematic because of potential pharmacological interactions with antiretroviral compounds and other antimicrobial agents, associated with an increased risk of toxicity and intolerance.

Eight years after the introduction of HAART as the standard therapy of HIV disease, around one fifth of treated patients of our cohort still rely on isolated dual nucleoside analogue administration, mostly due to an apparently effective treatment initiated with these last drugs before the HAART era, or severe intolerance to triple regimens based on protease inhibitors or non-nucleoside reverse transcriptase inhibitors, or patient's refusal of HAART. Three representative case reports are described, and their implications discussed on the ground of current guidelines of antiretroviral therapy and common clinical practice.

The Severe Acute Respiratory Syndrome (SARS) is a new life-threatening respiratory disease which has its origins in Guangdong province, China, where the earliest known cases were identified in November 2002. Since then, probable cases of SARS have been reported in 30 countries and the current cumulative number of cases is 8,240 with 745 deaths and a global fatality rate of 9%. The most frequently involved areas include China, Hong Kong, Singapore, Canada, Vietnam and Philippines. Most cases of SARS to date have occurred in young adults and this disease appears to spread most commonly by close person-to-person contact, involving exposure to infectious droplets and body fluids. This transmission pattern generally involves household members, health care workers and international travellers, while a large and sudden cluster of almost simultaneous cases in an housing estate of Hong Kong has raised the possibility of transmission from an environmental source. The most common presenting symptoms are fever, malaise, non-productive cough and dyspnea, associated with pulmonary interstitial infiltrates on chest radiography. A novel coronavirus is associated with this outbreak, and the laboratory evidences indicate that this virus has an etiologic role in SARS, but the role of other concurrent viral agents (such as metapneumovirus) identified in these patients requires further investigation.

Both HIV disease and chronic HBV and HCV hepatitis recently benefited by significantly improved combination antiviral treatments, which, led to a remarkably increased life expectancy, and reduced morbidity and mortality rates of these potentially life-threatening disorders. However, many problems still wait definite solutions. Among them, the liver toxicity expected from administration of complex antiviral regimens (especially when co-infection is of concern), potential drug-drug interactions, the still unknown pathogenetic connections with the broad spectrum of metabolic abnormalities complicating long-term antiretroviral treatment, and the expected outcome of these issues on clinical management, therapeutic monitoring, and disease prognosis.

Antimicrobial susceptibility levels of Enterococcus faecalis isolated from urine were followed up at our University Hospital during three years (1999-2001), in order to evaluate the trend of antibiotic resistance of this common community-acquired pathogen of the genito-urinary tract. One thousand and 249 consecutive strains were examined, and a surprisingly low resistance profile was detected. As a result, penicillin , ampicillin, nitrofurantoin and piperacillin may still represent first-line agents in our area when community-acquired urinary tract enterococcal infections is of concern, pending in vitro susceptibility studies.

The selective pressure of extended broad-spectrum antibiotic administration is leading to a progressively growing selection of common gram-positive and gram-negative organisms which show unpredictable in vitro antimicrobial susceptibility levels to current first-line therapeutic choices. This phenomenon is examined from an epidemiological, microbiological, therapeutical, and pharmacoeconomic point of view, focusing our attention on the most common community-acquired infectious diseases interesting upper and lower airways, genito-urinary and gastrointestinal tract, skin and soft tissues. A broad spectrum of variables is responsible for this ever changing scenario, whose solution cannot be entrusted to the development of new compounds, but it first relies on a rational and judicious administration of existing molecules, and an expanded medical and patient interaction aimed at avoiding overprescription of antimicrobial agents.

Although HIV infection is often associated with several rheumatic diseases, the coexistence of this retroviral infection and systemic lupus erythematous is extremely uncommon. Etiopathogenetic relationship between these disorders is very complex and still problematic, so that diagnostic workout, because of their extensive clinical and serological overlap. Generally, HIV-related immunosuppression improves lupus-associated symptoms, and antiretroviral therapy may lead to an autoimmune disease flare, subsequent to the increase of circulating CD4+ cell number. A HIV-infected female patient with systemic lupus erythematosus, occurred few months after the highly active anti-retroviral therapy initiation, is described.