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Cystinosis is an inherited metabolic disorder caused by recessive mutations in the CTNS gene. The disease primarily affects the kidneys followed by extra-renal organ involvement later in life. Azoospermia is one of the unclarified complications which is not improved by cysteamine treatment, the only available disease-modifying treatment. We aimed at unravelling the origin of azoospermia in cysteamine-treated cystinosis by confirming or excluding an obstructive factor, and investigating the effect of cysteamine on fertility in the Ctns-/- mice model compared to wild-type. Azoospermia was present in the vast majority of infantile type cystinosis patients. While spermatogenesis was intact either at testicular or epididymal level in cystinosis patients, an enlarged caput epididymis and reduced levels of seminal markers for obstruction Neutral α-Glucosidase (NAG) and extracellular matrix protein 1 (ECM1) pointed towards an epididymal obstruction. Transcriptomic analysis of CTNS KD in a fertile human caput epididymal cell line demonstrated upregulation of pathways related to inflammation and cell polarization. Interestingly, histopathological examination in human and mice revealed a disturbed blood-testis barrier (BTB) characterized by an altered zonula occludens-1 (ZO-1) protein expression. Animal studies ruled out a negative effect of cysteamine on fertility, and showed that cystine in the testes is irresponsive to regular cysteamine treatment. We conclude that the azoospermia in infantile cystinosis is due to an obstruction related to epididymal dysfunction, irrespective of the severity of an evolving primary hypogonadism as an additional non-obstructive process. Regular cysteamine treatment does not affect fertility but has subtherapeutic effects on cystine accumulation in testes. This article is protected by copyright. All rights reserved.

Candida parapsilosis infections are increasingly reported in preterm neonates, but the optimal treatment remains uncertain. We report the clinical history of an extremely preterm neonate, who developed a devastating skin necrosis due to terlipressin administration, with subsequent superinfection by Candida parapsilosis. The infant underwent multiple curettages and skin grafts to resolve skin lesions and was treated with systemic micafungin administration at a high dose (8 mg/kg/day), with resolution of the fungal infection.

Dear editor,Digoxin is a cardioactive drug with a narrow therapeutic window. Severe intoxication may require urgent treatment. The clinical picture is represented by dangerous dysrhythmias and the ...

Limited data are available on the most appropriate dosing, efficacy, and safety of micafungin in neonates and young infants with invasive candidiasis (IC). This study evaluated plasma levels, efficacy, and safety of micafungin at a dose of 8 mg/kg daily for a mean of 13.3 days (±5.2 days) in 35 neonates and young infants with IC. Micafungin plasma concentrations were 5.70 mg/liter preadministration and 17.23, 15.59, and 10.27 mg/liter after 1, 2, and 8 h, respectively. The resolution of the infection was achieved in 86.7% of patients treated for ≥14 days. In 20.0% of patients, we observed a transient hypertransaminasemia. Micafungin at a dose of 8 mg/kg daily is effective and well tolerated in neonates and young infants with IC. (This study has been registered at ClinicalTrials.gov under identifier NCT03421002 and in the EU Clinical Trials Register under number 2014-003087-20.).

Background Linezolid is a synthetic antibiotic which is active against most Gram-positive bacteria, especially on Staphylococcus aureus. Its administration can be required when the infection is due to staphylococcus strains, which are resistant to vancomycin. Although mostly well tolerated, some mild to moderate side effects have been reported. Case presentation This case report describes an infant with multiloculated hydrocephalus, staphylococcal meningitis and prolonged linezolid therapy, in which we observed the association between linezolid administration and a lengthened QTc interval at the electrocardiogram (ECG). To rule out toxic levels during the therapy, plasma and cerebro-spinal fluid concentrations of linezolid were measured and reported. Conclusions Although generally well tolerated in neonates and infants, linezolid prolonged administration seems be able to cause QTc interval prolongation. Therefore, its administration in such patients should be limited to cases of bacterial resistance to other antibiotics. In addition to well-known close monitoring of the platelet level, we suggest serial ECG controls before and during linezolid administration. In the case we report, linezolid plasma concentrations resulted within the therapeutic range during therapy, while cerebrospinal fluid (CSF) concentrations appeared lower than those considered effective.

This is the third in a planned series of data papers presenting modelled vector distributions produced during the ECDC and EFSA funded VectorNet project. The data package presented here includes those 'Culicoides' vectors species first modelled in 2015 as part of the VectorNet gap analysis work namely 'C. imicola, C. obsoletus, C. scoticus, C. dewulfi, C. chiopterus, C. pulicaris, C. lupicaris, C. punctatus, and C. newsteadi'. The known distributions of these species within the Project area (Europe, the Mediterranean Basin, North Africa, and Eurasia) are currently incomplete to a greater or lesser degree. The models are designed to fill the gaps with predicted distributions, to provide a) first indication of vector species distributions across the project geographical extent, and b) assistance in targeting surveys to collect distribution data for those areas with no field validated information. The models are based on input data from light trap surveillance of adult 'Culicoides' across continental Europe and surrounding regions (71.8°N –33.5°S, – 11.2°W – 62°E), concentrated in Western countries, supplemented by transect samples in eastern and northern Europe. Data from central EU are relatively sparse. Funding statement: This work was carried out with support from the VectorNet framework contract OC/EFSA/AHAW/2013/02-FWC1 funded by the European Centre for Disease prevention and Control (ECDC) and the European Food Safety Agency (EFSA) and the PALE-Blu H2020 Project ID: 727393.

Adverse drug reactions occur at a high rate in hospitalized children, frequently due to antiepileptic drug administration. Phenytoin is a commonly used drug, and its metabolism is mediated by a specific cytochrome-P450 isoform, CYP2C9, which is encoded by a polymorphic gene. It is worth noting that very frequently administered drugs, such as proton pump inhibitors, compete with phenytoin for CYP2C19-mediated metabolism. Here we describe a case of phenytoin intoxication in a child with defective CYP2C9, after omeprazole administration.

Dear Editor,Deferasirox (DFR) is an oral chelator used in transfusion-dependent patients with hematological diseases [1]. Recommended dosage is 20–30 mg/kg/d, but some patients require doses >30 mg...

Eltrombopag is an oral thrombopoietin receptor agonist approved for the treatment of patients with chronic idiopathic thrombocytopenic purpura (ITP), who are more than 1 year old, and show poor response to first-line therapy. ITP is a hematological disorder characterized by isolated thrombocytopenia in the absence of secondary causes or disorders. Eltrombopag is generally well tolerated in the pediatric population; therefore, therapeutic drug monitoring (TDM) is not usually performed in clinical practice.We presented the case study of a 3-year-old girl with chronic ITP. She arrived in the pediatric intensive care unit with acute liver failure due to eltrombopag toxicity despite taking the standard drug dosage. A very high eltrombopag plasma concentration, indicating drug toxicity, was found through TDM. The patient also carried the allelic variations that are involved in drug metabolism [CYP2C8 and UDP glucuronosyltransferase (UGT) 1A1 (UGT1A1)] and drug cellular transportation [ABCG2 (ATP-binding cassette G2)]. This observation highlights the importance of using TDM and pharmacogenetic approaches to manage patients' unusual complications associated with standard pharmacological treatment regimens.

Fungal infections may complicate the neonatal clinical course, and the spectrum of therapies for their treatment in the perinatal period is limited. Polyenes, Azoles and Echinocandins represent the three classes of antifungal drugs commonly used in the neonatal period. The present review provides an overview about the most recent therapeutic strategies for the treatment of fungal infections in neonates.

The increased survival of urea cycle disorders (UCDs) patients has led the attention to clinical manifestations that characterize the long-term disease course. Acute and chronic liver disease have been anecdotally reported since the very first description of UCDs. However, a detailed analysis of long-term liver involvement in large patient cohorts is still needed. Chronic liver damage in UCDs has probably a multifactorial origin, but the specific underlying mechanisms of liver disease have not yet been well elucidated. In this study, we report on chronic liver involvement and on associated metabolic abnormalities in a large cohort of 102 UCD patients, followed by two reference centers in Italy. Chronic liver involvement was observed in over 60% of UCDs patients, and comparison between individual diseases showed a significant higher frequency in argininosuccinate lyase deficiency (ASLD) and in hyperornithinemia-hyperammonemia-homocitrullinemia (HHH) syndrome with elevation of transaminases and of gamma-GT in ASLD, and of alpha-fetoprotein in HHH syndrome. Also, consistent with a chronic hepatic dysfunction, ultrasound examination revealed more pronounced abnormalities in ASLD and in HHH syndrome, when compared to other UCDs. Our study highlights in a large UCDs patients' cohort that chronic liver disease is a common finding in UCDs, often with a distinct phenotype between different diseases. Furthers studies are needed to elucidate the specific involvement of different metabolic pathways in the pathogenesis of liver dysfunction in UCDs.

Gram-negative bacilli septic thrombosis (GNB-ST) represents a subtle and often misleading condition, potentially fatal if not recognized early and requiring prolonged antimicrobial therapy and anticoagulation. Herein, reported for the first time, is a very challenging case of Klebsiella producing carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) ST unresponsive to ceftazidime/avibactam (CZA) relapsed first with meropenem/vaborbactam (MVB) monotherapy and subsequently cured with MVB plus fosfomycin (FOS) combination. The present case highlights the possibility of CZA underexposure on the infected thrombus and the risk of in vivo emergence of CZA resistance in the setting of persistent bacteremia and sub-optimal anticoagulation. Pharmacokinetic analyses showed that both MVB and FOS were in the therapeutic range. In vitro studies demonstrated a high level of MVB + FOS synergism that possibly allowed definitive resolution of the endovascular infection.

High doses of micafungin are advocated in neonates with systemic candidiasis, but limited pharmacokinetic (PK) and safety data are available to support their use. Eighteen preterm neonates and infants with systemic candidiasis, three of whom had meningitis, were treated for at least 14 days with 8 to 15 mg/kg of body weight/day of intravenous micafungin. Plasma micafungin concentrations (four measurements for each patient) were determined after the third dose, and the cerebrospinal fluid (CSF) micafungin concentrations in three patients were also obtained. Population PK analyses were used to identify the optimal model, and the model was further validated using external data ( n = 5). The safety of micafungin was assessed by measurement of the levels of liver and kidney function biomarkers. The mean age and weight at the initiation of treatment were 2.33 months (standard deviation [SD], 1.98 months) and 3.24 kg (SD, 1.61 kg), respectively. The optimal PK model was one that scaled plasma clearance to weight and the transaminase concentration ratio. The CSF of three patients was sampled, and the observed concentrations were between 0.80 and 1.80 mg/liter. The model-predicted mean micafungin area under the concentration-time curve over 24 h was 336 mg · h/liter (SD, 165 mg · h/liter) with the 10-mg/kg/day dosage. Eighteen of the 23 subjects (78.2%) had clinical resolution of their infection, but 5 had neurologic impairments. Among the transaminases, alkaline phosphatase measurements were significantly higher posttreatment, with a geometric mean ratio of 1.17 (90% confidence interval, 1.01, 1.37). Furthermore, marked elevations in the gamma-glutamyltransferase (GGT) level were observed in three patients treated with 10- to 15-mg/kg/day doses, and improvement of the GGT level was noted after a dose reduction. Higher weight-based doses of micafungin were generally well tolerated in neonates and infants and achieved pharmacokinetic profiles predictive of an effect.

Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.

Major gaps exist in our knowledge of antimicrobial pharmacokinetics in critically ill neonates and infants that require validated microsampling and bioanalysis methods to support therapeutic drug monitoring. We compared serially collected intravenous (i.v.) and heel stick capillary (HSC)-sampled plasma concentrations of micafungin (8 mg/kg) in eight infants born preterm with systemic candidiasis. The mean (standard deviation) micafungin area under the plasma concentration-time curve to infinity (AUC(inf)) was 316 (65.0) h · mg/liter based on HSC concentrations that strongly correlated (R(2) = 0.92) with i.v. values to support dose adjustment.

Background This study aimed to explore inter-individual variability of cefoxitin trough levels, predictors of serum cefoxitin concentration and the probability of target attainment of drug levels above 4 mg/L after pediatric cardiac surgery. Methods Retrospective study on children scheduled for elective cardiac surgery and having cefoxitin trough levels available up to 24 hours postsurgery. Results Overall, 68 children (9 neonates, 34 infants, 15 children below or equal to 10 years old and 10 patients above this age) were included. Of these, 16 surgeries were performed off cardiopulmonary bypass and 52 were performed on cardiopulmonary bypass. The free cefoxitin concentrations showed a median (interquartile range) concentration of 1.7 (0.6-4.2) mg/L. The range of cefoxitin concentrations showed a 150-fold and 340-fold variability at cardiac intensive care unit admission and after 24 hours, respectively. The pharmacodynamics (PD) targets of free cefoxitin at 100% of the dosing interval, considering Eucast breakpoints for Methicillin Sensitive Staphylococcus Aureus (4 mg/L) and E.Coli (8 mg/L), were obtained in 28% and 16% of patients, respectively. Patient weight (odds ratio, 0.7; 95% confidence interval, 0.62-0.92; P = 0.006) and serum creatinine concentrations (odds ratio, 25; 95% confidence interval, 18-36; P = 0.004) showed a significant relationship with the PD targets. Conclusions Cefoxitin trough concentrations vary significantly in the first 24 hours after pediatric cardiac surgery. Both serum creatinine and body weight showed independent associations with cefoxitin concentration. The PD target was not obtained in the vast majority of the explored population, regardless of the target bacteria.

Rift Valley fever (RVF) is a severe mosquito-borne disease that is caused by a Phlebovirus (Bunyaviridae) and affects domestic ruminants and humans. Recently, its distribution widened, threatening Europe. The probability of the introduction and large-scale spread of Rift Valley fever virus (RVFV) in Europe is low, but localized RVF outbreaks may occur in areas where populations of ruminants and potential vectors are present. In this study, we assumed the introduction of the virus into Italy and focused on the risk of vector-borne transmission of RVFV to three main European potential hosts (cattle, sheep and goats). Five main potential mosquito vectors belonging to the Culex and Aedes genera that are present in Italy were identified in a literature review. We first modelled the geographical distribution of these five species based on expert knowledge and using land cover as a proxy of mosquito presence. The mosquito distribution maps were compared with field mosquito collections from Italy to validate the model. Next, the risk of RVFV transmission was modelled using a multicriteria evaluation (MCE) approach, integrating expert knowledge and the results of a literature review on host sensitivity and vector competence, feeding behaviour and abundance. A sensitivity analysis was performed to assess the robustness of the results with respect to expert choices. The resulting maps include (i) five maps of the vector distribution, (ii) a map of suitable areas for vector-borne transmission of RVFV and (iii) a map of the risk of RVFV vector-borne transmission to sensitive hosts given a viral introduction. Good agreement was found between the modelled presence probability and the observed presence or absence of each vector species. The resulting RVF risk map highlighted strong spatial heterogeneity and could be used to target surveillance. In conclusion, the geographical information system (GIS)-based MCE served as a valuable framework and a flexible tool for mapping the areas at risk of a pathogen that is currently absent from a region.

OBJECTIVE: The primary aim of this study was to assess cognitive development, in particular that of executive functions (EFs), and behavioral findings for patients with early treated phenylketonuria (PKU). Furthermore, we evaluated the relationships of our findings with plasma levels of Phe and adherence to dietary prescriptions. METHODS: A cross-sectional design was adopted. Patients who had early treated PKU, who were older than 4 years, and who were regularly seen by a physician were enrolled in the study. Cognitive development was assessed with Wechsler Scales appropriate to the chronological age of subjects in the study. Executive functions were assessed using the Tower of London test, and behavioral findings were quantified with the Child Behavior Checklist. RESULTS: Thirty-five patients were enrolled (mean age 11.5 years, SD ± 6.2). The mean Full Scale intelligence quotient was in the normal range (93.4 ± 17.4), without significant difference between the verbal intelligence quotient (mean, 94.3 ± 16.1) and performance intelligence quotient (mean, 93.9 ± 18.0). The majority of patients showed a deficit within the EF domain of cognitive abilities (mean lower than 1.8 SD of the normal mean), 8 of them showing a score

Medulloblastoma (MB) is the most common malignant brain tumor in children. Despite therapeutic advancements, high-risk groups still present significant mortality. A deeper knowledge of the signaling pathways contributing to MB formation and aggressiveness would help develop new successful therapies. The target of rapamycin, mTOR signaling, is known to be involved in MB and is already targetable in the clinical setting. Furthermore, mTOR is a master metabolic regulator able to control cell growth versus autophagy decisions in conditions of amino-acid deprivation that can be due to IDO1 enzymatic activity. IDO1 has been also implicated in the regulation of inflammation, as well as of T cell-mediated immune responses, in a variety of pathological conditions, including brain tumors. In particular, IDO1 induces expansion of regulatory T-cells (Treg), preventing immune response against tumor cells. Analysis of 27 MB tissue specimens for the expression of both mTOR and IDO1 showed their widespread expression in all samples. Testing their cooperation in vitro, a significant involvement of IDO1 in mTOR immunogenic pathway was found, able to counteract the aim of rapamycin treatment. In MB cell lines, inhibition of mTOR strongly induced IDO1 expression and activity, corroborating its ability to recruit Treg cells in the tumor microenvironment. The mTOR/IDO1 cross talk was found to be strictly specific of MB cells. We demonstrated that mTOR pathway cross talks with IDO1 pathway to promote MB immune escape, possibly contributing to failure of mTOR- targeted therapy.

Several researchers have found that plasma citrulline could be a marker of reduced enterocyte mass. The aim of this study was to assess the relationship between plasma citrulline and bowel inflammation and/or disease location in pediatric and adolescent Crohn's disease (CD) patients.Between January 2008 and January 2010, 31 CD patients and 44 controls were included in our study, and 15 out of the 31 CD patients continued a prospective survey. We evaluated the differences between groups, at baseline, in plasma citrulline and glutamine and between their baseline and final values during the prospective survey, and correlation between baseline values of citrulline and duration of disease, C-reactive protein, and fecal calprotectin.Mean citrulline value was 33.0 ± 7.5 μmol/L in controls and 23.5 ± 8.4 μmol/L in CD patients (P 0.0001). Plasma citrulline was significantly lower in patients with small bowel (SB) location than in patient with only ileo-colon disease (14.2 ± 5.5 and 24.7 ± 8.0, respectively; P = 0.0037). Citrulline ≤22 μmol/L reached sensitivity of 100% (95% confidence interval (CI) 54-100) and specificity of 98% (CI 89-99) in differentiating control subjects from CD with SB location.CD patients have reduced concentration of plasma citrulline than controls. Intestinal damage rather than inflammation seems to be responsible for the reduced biosynthesis of citrulline, which decreases particularly in CD patients with SB location. This finding suggests the potential role of citrulline as marker of disease location, but future works will be needed to confirm this suggestion.

Aim: To investigate adherence to dietary treatment and quality of life (QoL) in patients with phenylketonuria (PKU). Methods: In the setting of a tertiary paediatric hospital, 41 early-treated patients affected by PKU aged more than 3 years old were enrolled in a cross-sectional study. Three-days dietary assessment, QoL questionnaires for patients

Dear Editor, We read with interest the paper from Papadia et al. [1] that suggests the potential role of the serum citrulline (CIT) level as biomarker of malabsorption. Intestinal CIT originates from the intestinal villi located in the proximal small bowel, which justifies its potential usefulness in the diseases associated with villous atrophy such as celiac disease (CD) [1]. Currently, the serological screening for suspected pediatric CD is based on the two major serological markers represented by the anti-transglutaminase type 2 (tTG) and by the anti-endomysial antibodies (EMA) [2]. Recently a third antibody against deamidated forms of gliadin peptides (DGP) has been identified that seems to be more sensitive in young children [2]. However, all these auto-antibodies may be undetectable in some clinical conditions [2]. In these cases, the diagnosis of CD may be supported by a screening tool not based on the evaluation of antibodies, but seemingly predictive of intestinal atrophy. From this perspective, the use of the CIT level might be helpful. We would like to report our experience with the CIT level in subjects highly suspected for CD. In 2011, we planned a prospective study to evaluate whether the serum CIT level might be included in a practical diagnostic work up of subjects with suggestive symptoms for CD. The setting of our study was the Hepatology, Gastroenterology and Nutrition Unit of ‘‘Bambino Gesu’’ Children’s Hospital in Rome. Between June 2011 and March 2012, all patients referred for suspected CD were enrolled. In all suspected CD subjects, a blood sample for IgA, tTG of IgA class, EMA, serum CIT and creatinine was taken. The biological sampling of CIT was made during stable clinical conditions and in a post-absorptive state and determined by RF-HPLC. In patients with IgA deficiency (total IgA B 5 mg %), we assessed the tTG of IgG class [3]. A biopsy was performed in all suspected CD, with suggestive symptoms isolated or associated with positive tTG/EMA. In agreement with the recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition [3], type 3 specimens according to Marsh-Oberhuber classification [4] were considered characteristics of CD. The Marsh 1 and 2 lesions were considered nonspecific, but in line with the CD diagnosis in presence of positive tTG/EMA [3]. In patients with Marsh 3 lesions and negative tTG/EMA, HLA-DQ was assessed, and the symptoms were evaluated after starting a glutenfree diet (GFD). The patients with positive HLA-DQ2 and DQ8 and disappearance of the symptoms on a GFD were considered as CD cases. During the same period we enrolled all consecutive CD patients on a GFD. The inclusion criteria were the following

Citrullinaemia is a rare inborn error of urea cycle metabolism. We describe the MRI findings in a 16-year-old boy with type I citrullinaemia during an episode of acute hyperammonaemic encephalopathy and compare them to his previous follow-up MRI studies. MRI revealed bilateral high signal intensity in the cingulate, perirolandic, parietal and temporoinsular cortex, the subcortical white matter and left thalamus. Diffusion-weighted imaging showed high signal intensity and low apparent diffusion coefficient values in the frontoparietal lobes. To our knowledge, MRI findings in an adolescent with type I citrullinaemia have not been previously reported. Since our patient's neuroradiological findings showed greater similarity to type II citrullinaemia, we think his brain injury during this acute episode was probably age-related and independent of the type of citrullinaemia.

Summary In August 2000 bluetongue (BT) disease appeared amongst sheep on the island of Sardinia spreading later to Sicily and to mainland Italy. The majority of areas affected by BT were surveyed for Culicoides imicola, the only proven vector of the disease known to occur in the Mediterranean region. The data from 1456 light-trap collections, made in months with a mean temperature of 12.5°C, were used to test the accuracy of current models predicting the prevalence and abundance of C. imicola across the region. For Italy, the distribution of C. imicola was found to be very irregular and did not fit the modelled predictions. The possible reasons for this are discussed, and suggestions made as to which variables may improve this fit in the development of future risk models. In Italy, past surveys failed to reveal the presence of C. imicola, and so could be construed as evidence of its recent invasion, and thus rampant spread northwards. Although equivocal, historical records indicate that C. imicola was overlooked in the past. Six recommendations are made as to the possible future course of Culicoides research in southern Europe.

So-called lock therapy, consisting of high concentrations of antimicrobials instilled into the lumen of the catheter, has been suggested avoid central venous catheter removal during fungal infection. We report a baby who developed catheter-related candidemia. Systemic antifungal treatment did not resolve the candidemia. Lock therapy with 0.3 mL of ethanol 70% and micafungin sodium 5 mg/L was added to the therapy, and blood cultures became sterile.

We report the case of a 3-year-old girl affected by major thalassemia. She was treated with Deferasirox (DFR), an oral iron chelator, at the dosage of 33 mg/kg per day since the age of 2 years. During the following months, the child underwent three admissions for fever, vomiting, metabolic acidosis, increased azotemia and dehydration. One episode

In addition to systemic manifestations with skeletal, pulmonary, renal, and haematological signs, lysinuric protein intolerance (LPI), a membrane transport defect of cationic amino acids, is often complicated by severe life-threatening immunological manifestations. A 10-year-old boy with LPI who exhibited a severe systemic immunohaematological disease is described here. This patient showed cutaneous lesions similar to the subacute form of systemic lupus erythematosus, severe anaemia and dysproteinaemia, and a marked reduction of circulating T lymphocytes, mainly the CD4+ cells. In vitro bone marrow cell culture studies showed that addition of patient's serum induced macrophage proliferation and inhibited erythroid progenitor cell growth. Treatment with high-dose intravenous immune globulin resolved most of the clinical and laboratory abnormalities.

A wide range of arthropod-borne viruses threaten both human and animal health either through their presence in Europe or through risk of introduction. Prominent among these is West Nile virus (WNV), primarily an avian virus, which has caused multiple outbreaks associated with human and equine mortality. Endemic outbreaks of West Nile fever have been reported in Italy, Greece, France, Romania, Hungary, Russia and Spain, with further spread expected. Most outbreaks in Western Europe have been due to infection with WNV Lineage 1. In Eastern Europe WNV Lineage 2 has been responsible for human and bird mortality, particularly in Greece, which has experienced extensive outbreaks over three consecutive years. Italy has experienced co-circulation with both virus lineages. The ability to manage this threat in a cost-effective way is dependent on early detection. Targeted surveillance for pathogens within mosquito populations offers the ability to detect viruses prior to their emergence in livestock, equine species or human populations. In addition, it can establish a baseline of mosquito-borne virus activity and allow monitoring of change to this over time. Early detection offers the opportunity to raise disease awareness, initiate vector control and preventative vaccination, now available for horses, and encourage personal protection against mosquito bites. This would have major benefits through financial savings and reduction in equid morbidity/mortality. However, effective surveillance that predicts virus outbreaks is challenged by a range of factors including limited resources, variation in mosquito capture rates (too few or too many), difficulties in mosquito identification, often reliant on specialist entomologists, and the sensitive, rapid detection of viruses in mosquito pools. Surveillance for WNV and other arboviruses within mosquito populations varies between European countries in the extent and focus of the surveillance. This study reviews the current status of WNV in mosquito populations across Europe and how this is informing our understanding of virus epidemiology. Key findings such as detection of virus, presence of vector species and invasive mosquito species are summarized, and some of the difficulties encountered when applying a cost-effective surveillance programme are highlighted., Data from Italy were provided by the National and Regional Surveillance Programs supported by the Ministry of Health and the Regional authorities of Veneto, Fruili Venezia Giulia, Emilia and Lombardia. IPZ highly acknowledges the financial contribution of the Swiss Federal Veterinary Office (grant 1.12.17 and National Centre for Vector Ecology). Acknowledgements to the Federal Office for the Environment for financing the mosquito collection activity and the Federal Office for Civil Protection for financing the molecular analysis. Surveillance in Greece was funded by contributions from the Hellenic Centre for Disease Control and Prevention and the Development Agency of Thessaloniki S.A. Spanish surveillance for West Nile virus and mosquitoes has been funded by Projects from the European Union (EDEN, Eurowestnile and EDENext), Spanish Ministry of Health (EVITAR), Spanish Ministry of Economy and Competitivity (CGL2009-11445 and CGL2012-30759) and Junta de Andalucía (P07-RNM-02511 and P11-RNM-7038). Nicholas Johnson is funded by Defra grant SE4112 (Development of reseach tools to support arthropod-borne virus investigation). Anthony J. Wilson is funded by the Biotechnology and Biological Sciences Research Council (grant number BBS/B/00603).

A novel method was developed and implemented during the recent outbreak of bluetongue (BT) in sheep and cattle in The Netherlands to obtain rapidly a ‘snapshot’ of Culicoides vector densities at the national level. The country was divided into 110 raster cells, each measuring 20 km × 20 km; within 106 of these cells, a farm was selected with a minimum of 10 cattle and sampled for Culicoides for one night only using the Onderstepoort-type blacklight trap. Prior to deployment of the light traps in the field, local veterinarians were trained in their use and in the preservation of captured Culicoides. The collections were despatched daily by courier to a field laboratory where the Culicoides were counted and identified. The ‘snapshot’ commenced on 12 September 2006 and was completed on 28 September coinciding with the 5–7 weeks of BT virus (BTV) activity in The Netherlands and when the number of weekly cases of disease was on the rise. Analysis of the 106 collections was completed on 5 October. The number of grid cells in which a taxon occurred is represented by the index 20 2 gFR (=20 km × 20 km grid Frequency Rate); this index essentially reflects the percentage of examined raster cells found to contain the potential vector in question. The ‘snapshot’ results can be summarised as follows: • A total of >35,000 Culicoides were captured ( μ = 333 midges/light trap) representing 16 species; • Not a single specimen of C. imicola , the principal Afro-Asiatic vector of BTV in southern Europe, was captured; • The three European species of Culicoides implicated previously as potential vectors in the Mediterranean region and the Balkans also occur in The Netherlands; • The Obsoletus Complex (represented by both potential vectors Culicoides obsoletus and Culicoides scoticus ) was the most prevalent taxon (20 2 gFR: 93.4%) followed by the Pulicaris Complex (76.4%); • The Pulicaris Complex comprised at least six species. One of these, Culicoides pulicaris sensu stricto ( ss ), a potential vector in southern Europe, had a low 20 2 gFR of 17.9% indicating it played no role in the transmission of BTV; • The next most prevalent taxa were Culicoides dewulfi (70.8%) and Culicoides chiopterus (67.0%) both of which breed in cattle dung. This close association with livestock raises their potential as vectors of BTV; • Culicoides achrayi, Culicoides circumscriptus, C. dewulfi, Culicoides halophilus, Culicoides lupicaris and Culicoides stigma are new species records for The Netherlands and demonstrates that the extant knowledge on the Culicoides fauna of northern Europe is incomplete; • Cooling trends in the weather induced a >50-fold decrease in overall Culicoides numbers but with subsequent warming these would rebound rapidly indicating that more intense cold is required before heightened mortalities are induced amongst adult biting midges. The northward advance of BT in Europe compels the competent authorities in affected and in neighbouring territories to acquire rapidly baseline information around which to plan sound vector surveillance and livestock movement strategies. The Culicoides ‘snapshot’ is a tool well suited to this purpose. It is stressed that a vector surveillance program must be built upon a firm taxonomic base because misidentifications will flaw the mapped seasonal and geographic distribution patterns upon which veterinary authorities depend.