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Histoplasma capsulatum is an opportunistic dimorphic fungus responsible for most often self-limiting or flu-like infections but potentially lethal in immunocompromised hosts. Histoplasmosis is rare in Europe. We reported a case of disseminated histoplasmosis in an African HIV patient with a leprosy-like primary cutaneous presentation and involvement of lungs, brain, limphnodes and eye. The therapy with liposomial B amphotericin and itraconazole led to a prompt resolution of the symptoms.

In patients with Strongyloides stercoralis infection, a dysregulation of host immunity can lead to hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), characterized by high fatality rate. HS has been reported in HIV-positive patients following use of corticosteroids or during immune reconstitution inflammatory syndrome (IRIS). A retrospective study was conducted to estimate the prevalence of S. stercoralis infection among HIV-positive immigrants, attending two Italian hospitals. From January 2000 to August 2009, 138 HIV-positive immigrants were systematically screened for strongyloidiasis, as a part of their routine care, with an indirect immunofluorescent antibody test (IFAT) developed at the Centre for Tropical Diseases, Sacro Cuore Hospital of Negrar, Verona. The majority were also submitted to stool examination. Fifteen (11%) resulted infected by S. stercoralis, of whom four (27%) had a negative serology (diagnosis made with stool examination). A higher eosinophil count (0·94 versus 0·24×10(9)/l, P<0·01) and more frequent gastrointestinal and cutaneous symptoms (odds ratio: 4·8 and 5·8, respectively) were found in patients with strongyloidiasis compared with controls. The IFAT is more sensitive than direct parasitological methods. The proportion of false negative results was higher than expected based on the theoretical test sensitivity. Considering the high prevalence detected and the apparent, lower sensitivity of serology, we propose a systematic screening for Strongyloides infection, with both serology and stool culture, for all HIV-positive immigrants coming from endemic areas.

We report four imported cases of progressive disseminated histoplasmosis (PDH) due to Histoplasma capsulatum variety capsulatum in Human Immunodeficiency Virus-infected patients from West Africa. This report highlights the need to consider diagnosis of PDH among patients with acquired immunodeficiency syndrome who originate from West Africa and present with a prolonged febrile illness and very low CD4 count.

The aim of the study was to evaluate the epidemiology and the diagnostic, clinical and therapeutic aspects of immigrants affected by tuberculosis, hospitalized in 35 Italian Infectious Diseases Clinics during 2003. The data obtained showed that 300/2392 (12.5%) patients had active tuberculosis, 10.3% of whom had concomitant HIV infection. 53% of the patients were legal residents and were assisted by the National Health Service; 48.3% came from African regions. The mean length of residency in Italy at the time of hospitalization was 4 years. The main clinical forms were pulmonary (66%), lymph nodal (15.3%) and bone TB (5.3%). Drug resistance was demonstrated in 16% of cases with 9% cases of resistance to isoniazid, 8.2% to streptomycin, 5.1% to pyrazinamide, 2.6% to ethambutol, 2.6% to rifampicin; in 5.3% of cases a multiple resistance was demonstrated. A complete adherence to treatment was achieved in 213 patients. Statistical analysis disclosed a significant correlation between compliance with treatment and legal citizenship status. In conclusion, TB still represents an important disease among immigrants. Improved living conditions, both in countries of origin and in Italy, especially in the first few years, would certainly decrease the incidence of TB.

We describe a case of disseminated Penicillium marneffei in a human immunodeficiency virus (HIV)-positive Italian man who stayed for 4 years in Chiang Ray province, northern Thailand. A review of the literature shows that penicilliosis, although unusual, may represent an emerging opportunistic infection among HIV-positive people traveling to endemic areas.

In the present study, 67 patients suspected to be cases of visceral leishmaniasis (VL) were each checked for leishmanial infection by the microscopical evaluation of various biological specimens, in-vitro culture, serology and an assay based on nested PCR. Most (35) of the subjects were immunocompetent (IC) but 32 were immunodeficient (ID) as the result of HIV infection (18 cases), treatment to prevent transplanted organs being rejected (six) or haematological malignancies (eight). Forty-one (61.2%) of the subjects (19 IC subjects, 12 HIV-positive patients, four transplant patients and six patients with malignancies) were considered true cases of VL. For the IC subjects, only the production and microscopical examination of leucocytoconcentrates and cultures of Buffy coats gave sensitivities of <80%, the results of the other methods showing higher sensitivities and almost perfect agreement with the 'gold-standard' diagnoses. For the ID subjects, however, only the serological tests and the PCR gave reasonable sensitivities (of >80%). For the initial diagnosis of leishmaniasis in ID patients, IFAT and western blots may be useful, as, among the present ID patients, they gave sensitivities (of 80.9% and 88.2%, respectively) that were almost as high as that for the PCR, and specificities of 100%. In the diagnosis of VL in either IC or ID patients, the assay based on a nested PCR appeared to be particularly reliable, with sensitivities of 88.9% and 95.2%, respectively, and a specificity of 100% in both groups of patients. The testing of bone-marrow aspirates by PCR revealed very few VL cases who were not found positive when samples of their peripheral blood were checked in the same assay. For both IC and ID subjects therefore, the use of the PCR-based method to test samples of peripheral blood (which can be collected much more easily than bone-marrow aspirates and with much less pain for the subject) is recommended.

Highly active antiretroviral therapy (HAART) greatly reduces the risk of developing tuberculosis for HIV-infected persons. Nonetheless, HIV-associated tuberculosis continues to occur in countries where HAART is widely used. To identify the characteristics of HIV-infected persons who develop tuberculosis in the context of the availability of HAART, the current authors analysed data taken from 271 patients diagnosed, in Italy, during 1999-2000. These patients represent 0.7% of the 40,413 HIV-infected patients cared for in the clinical units participating in this current study. From the data it was observed that 20 patients (7.4%) had a previous episode of tuberculosis whose treatment was not completed. Eighty-one patients (29.9%) were diagnosed with HIV at tuberculosis diagnosis, 108 (39.8%) were aware of their HIV status but were not on antiretroviral treatment and 82 (30.3%) were on antiretroviral treatment. Patients on antiretroviral treatment were significantly less immunosuppressed than patients with HIV diagnosed concurrently with tuberculosis, or other patients not on antiretrovirals (median CD4 lymphocytes count: 220 cells x mm(-3) versus 100 cells x mm(-3), and 109 cells x mm(-3), respectively). No significant differences in clinical presentation of tuberculosis according to antiretroviral therapy status were recorded. Failure of tuberculosis control interventions (e.g. noncompletion of treatment) and of HIV care (delayed diagnosis of HIV infection and suboptimal uptake of therapy) may contribute to continuing occurrence of HIV-associated tuberculosis in a country where highly active antiretroviral therapy is largely available. However, a significant proportion of cases occur in patients who are on antiretroviral treatment.

We report two cases of histoplasmosis occurring in human immunodeficiency virus-positive patients who immigrated to Italy, and focus our attention on the clinical features and therapeutic aspects, with particular emphasis on secondary prophylaxis. The patients had comparable human immunodeficiency virus baseline parameters, but had a completely different compliance over therapeutic regimens. The two patients were followed in two different city hospitals of our region, Padua and Verona, and the diagnosis was made on the basis of instrumental, histologic, and microbiologic findings. One of them was treated with corticosteroids because of nephrotic syndrome.

Presented here are the results of a cohort study conducted on 3,483 consecutive HIV/AIDS patients between January 1993 and December 2000 to determine trends in AIDS incidence and presentation. The incidence of AIDS was calculated in the general population and examined further according to gender, age (< or = or >49 years), and heterosexual behaviour as a risk factor for HIV. Multivariate analysis was used to identify variables associated with AIDS presenters (defined as patients diagnosed with AIDS within 1 month of the first HIV-positive test). The numbers of patients with AIDS classified as (i) AIDS presenters, (ii) known HIV-positive patients on antiretroviral treatment, and (iii) known HIV-positive patients not receiving antiretroviral treatment were calculated. The overall incidence of AIDS decreased over time, mainly due to the lower number of patients on antiretroviral treatment developing AIDS. Factors associated with a higher risk of being an AIDS presenter were male gender and year of HIV diagnosis. Among patients with AIDS, the proportion of AIDS presenters increased from 13.8% prior to 1997 (when protease inhibitors were introduced in Italy) to 32.5% after 1997. Variables predictive of being an AIDS presenter were male gender, age at diagnosis, and AIDS diagnosis in the years 1997-2000. Heterosexuals had a higher risk of being AIDS presenters and a lower risk of being HIV-positive and not receiving antiretroviral treatment than intravenous drug users. In Italy, AIDS occurs mainly in subjects unaware of their HIV status (especially males, the elderly, and those infected heterosexually) or in patients refusing antiretroviral therapy (mainly intravenous drug users who do not refer to specialised centres).

Background: Stenotrophomonas (Xanthomonas) maltophilia has been increasingly reported as a nosocomial opportunistic pathogen, responsible for serious infectious complications in immunocompromised patients. At present very limited information is available concerning its clinical significance in the setting of HIV infection., Patients and Methods: A retrospective survey of clinical and microbiological records of 1,374 HIV-infected patients referring to our tertiary care center during a 10-year period (1991-2000) was performed to identify all episodes of S. maltophilia infection and analyze epidemiological, clinical and laboratory variables. The episodes of S. maltophilia bacteremia were compared with those caused by non-typhoid Salmonella spp. occurring in HIV-infected patients referring to our center during the same period, in order to evaluate eventual predisposing risk factors., Results: 61 episodes of S. maltophilia infection were observed in 59 HIV-infected patients: sepsis/bacteremia in 48 cases (78.7%), lower airways infection in five, urinary tract infection in four, pharyngitis in two, lymphadenitis and liver abscess in one case each. 47 of 61 episodes (77%) of S. maltophilia infection occurred as nosocomial disease (i.e. were diagnosed after the 3rd day of hospitalization) and bacterial isolates showed an elevated resistance profile against many beta-lactam compounds, aztreonam, imipenem and aminoglycosides. At the same time, 38 episodes of bacteremia due to non-typhoid Salmonella spp. were diagnosed in our patients, 13 of which were nosocomial infections., Conclusion: When compared with non-typhoid Salmonella spp. bacteremia, a significantly higher risk of developing S. maltophilia disseminated infection was seen in association with advanced immunodeficiency, leukopenia-neutropenia, central venous catheterization, prior broad-spectrum antimicrobial therapy and/or corticosteroid treatment.

Background: We studied the prevalence, epidemiological features, symptoms, diagnosis, treatment and outcome of invasive aspergillosis in AIDS patients in Italy., Patients and Methods: All patients affected by both aspergillosis and AIDS hospitalized between January 1986 and April 1997 (before highly-active antiretroviral therapy, HAART) in four Italian Department of Infectious Disease. Patients were included in the study only if culture, cytology or histology showed firm evidence of Aspergillus infection. Invasive aspergillosis was defined as the presence of characteristic, closely septate hyphae with repeated acute angle branching in either biopsy materials or percutaneous aspirates from tissues other than the lung. Hyphae were identified using hematoxylin-eosin and methenamine silver stain., Results: During the study, 54 out of 2,614 patients admitted with AIDS showed aspergillosis (2.1%). The disease usually occurred in patients with < 50 CD4 cells/mm(3). Aspergillosis was associated with neutropenia and steroid treatment. Nonspecific symptoms were frequently encountered. Fever and cough were both present in > 70% of the cases of pulmonary aspergillosis. Biopsy specimens were analyzed for definitive diagnosis. Invasive aspergillosis is usually treated with amphotericin B, but in 90% of the cases this did not prevent death., Conclusion: In AIDS patients with neutropenia and long-term steroid therapy, it is important to consider invasive aspergillosis in the differential diagnosis of opportunistic infections.

Background: Highly active antiretroviral therapy (HAART) is a combination of an HIV protease inhibitor (PI), one or two reverse transcriptase inhibitors (RTIs) and/or non-nuclease reverse transcriptase inhibitors (NNRTIs). This combination therapy is able to reduce peripheral HIV viral load, elevate CD4+ cell counts and improve the clinical outcome., Aim: To evaluate the impact of HAART therapy, including one PI, on the prevalence of skin diseases in patients with HIV/AIDS., Patients and Methods: The study was performed by collecting data about HIV populations followed at the 'M. Bufalini' Infectious Diseases Unit and San Patrignano Medical Centre, Italy. The medical records regarding the dermatological diseases of such people were retrospectively examined in 12-month periods before (1996) and after (1999) the introduction of HAART., Results: The two groups of patients were matched for age, gender and stage of HIV disease. During the first part of the study, 328 of the 456 patients (72%) sought medical advice 689 times for dermatoses. In the second period, 196 of the 502 patients (39%) made a total of 255 visits. There was a considerable decrease in the number of dermatological visits (-63%) and patients with dermatological problems (-40%). In the group that did not receive HAART, 66% of the patients had cutaneous infections, 25% had inflammatory cutaneous disorders, 8% adverse cutaneous drug reactions and 1% cutaneous neoplasms. In the group of patients treated with HAART, cutaneous infections were observed in 53% of patients, while 21% of patients had inflammatory dermatoses, 20% of patients showed adverse cutaneous drug reactions, and 1% had skin cancers. The remaining 5% asked to see a dermatologist for cosmetic reasons., Conclusions: The group of patients who received combination regimens including PIs had significantly lower cutaneous morbidity than those treated with nucleoside analogs alone. This tendency included both opportunistic infections and inflammatory cutaneous diseases. Adverse cutaneous drug reactions related to multidrug combination therapy were significantly higher in the group receiving HAART.

Histoplasmosis, which is highly endemic in the United States, is rare in Europe, usually imported but sometimes autochthonous. In Africa, histoplasmosis capsulati coexists with "African histoplasmosis", a characteristic skin infection caused by H. capsulatum var. duboisii. Histoplamosis due to H. capsulatum is one of the 12 secondary infections listed in the surveillance definitions of AIDS. We report the case of a 36-year-old black man with acquired immunodeficiency syndrome (AIDS) who was living in Italy but originally came from Ghana. Histoplasmosis was disseminated with fever and cutaneous manifestations. The diagnosis was demonstrated morphologically based on the presence of yeast, observed by light microscopy, in skin lesions and by identification of H. capsulatum var. capsulatum DNA by nested PCR from a paraffin sample. No clinical reports of histoplamosis capsulati in Ghana have been published until now. The present case stresses the role of immigration of subjects from outside Europe who have been infected in their native country.

We describe the first case of community-acquired bacteremia caused by Acinetobacter radioresistens; the patient was a 32-year-old HIV-positive neutropenic woman. Ambiguous Gram staining and poor biochemical reactivity of blood culture isolates misguided early diagnosis and therapy. Bacterial identification was based on 16S rDNA sequence analysis. A. radioresistens can be considered as a cause of opportunistic infection in immunodeficient patients.

The aim of this study was to assess the degree of implementation of national guidelines for isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV)-infected individuals and factors affecting the impact of the programme. Twenty-eight infectious disease hospital units in Italy participated in this observational, multicentre, prospective cohort study. A number of HIV-infected subjects, (n=1,705) seen for the first time as outpatients, were included in this analysis. Of the subjects considered, 1,215 out of the 1,705 completed purified protein derivative (PPD) screening. Variables independently associated with offering and completion of PPD screening included having acquired immune deficiency syndrome (AIDS), higher educational levels and currently receiving therapy. Overall, 103 subjects were identified as candidates for IPT. Of these subjects, five had tuberculosis and 15 had contraindications to IPT. Forty subjects agreed to start IPT, and 29 completed a full-course regimen. The incidence of tuberculosis among IPT candidates who either did not begin or discontinued IPT was 6.1 per 100 person-yrs, while no cases of tuberculosis were observed in subjects completing IPT. Several factors may limit the implementation of an isoniazid preventive therapy programme for human immunodeficiency virus-infected persons. Physicians fail to offer purified protein derivative screening to patients with high degrees of immunodeficiency, and those with a more intense workload seem to pay less attention to this test. The high number of contraindications among patients and their low level of acceptance further affects the impact of isoniazid preventive therapy.

Histoplasmosis is endemic in some areas of United States and in South America, and generally causes an acute self-limiting respiratory infection. In elderly and immunosuppressed patients the infection can spread through the blood, causing a severe systemic illness. Here we describe two cases of disseminated histoplasmosis in AIDS patients. The first was observed in an Italian woman who had never visited endemic countries, and was recognized only at autopsy; the second was observed in a trans-sexual patient, arrived in Italy from Brazil. Clinical suspicion of histoplasmosis is important in immunocompromised patients of non-endemic areas as symptoms are often aspecific and misdiagnosis is frequent.

Cytomegalovirus (CMV) infection was one of the most common opportunistic infections in AIDS patients, leading to blindness or life-threatening disease in about 40% of patients in the later stages of AIDS before highly active antiretroviral therapy (HAART). In a retrospective multicenter study we investigated the incidence of CMV retinitis and organ involvement in Northern Italy before (1995 and 1996) and after the introduction of HAART (1997 and 1998) as well as the data regarding CMV antigenemia. We found a sharp drop in the incidence of CMV disease in AIDS patients as well as a decline in the incidence of relapses of CMV-disease after the widespread introduction of HAART. Moreover, there was a decrease in the incidence of antigenemia-positive cases in AIDS patients in the era of HAART and the median CMV viral load was significantly higher in patients who didn't receive HAART than in patients who received HAART (p = 0.001, t test).

Objective: To evaluate time trends of the spectrum of AIDS-defining diseases in Italy, 1982-1996., Methods: Surveillance data from the Italian National AIDS Registry were used to assess temporal patterns of all AIDS-defining diseases diagnosed among adults as of December 1996. Twenty-six initial clinical manifestations of AIDS were grouped into 12 categories. Relative frequencies were calculated by year of diagnosis and stratified by age, gender, HIV-exposure category, and CD4+ cell count. A multivariate polychotomous logistic model was used to estimate the proportions of each diagnostic category over time, adjusting simultaneously for the remaining diagnostic categories and for variables of interest., Results: This analysis was based on 41772 diagnoses of AIDS-defining diseases among 36 638 reported cases. Mycoses represented the most frequent condition (27.3%), followed by Pneumocystis carinii pneumonia (PCP) (21.4%) and viral infections (8.9%). Cancers accounted for less than 10% of diseases. Downward trends were observed for mycoses, PCP (in the last part of the study period), Kaposi's sarcoma (KS), and non-Hodgkin's lymphomas (NHL). Upward trends were observed for mycobacterioses, and bacterial and protozoal infections. Brain toxoplasmosis increased up to 1994, and, thereafter, it appeared to decrease. These trends were less marked when the analysis was restricted to the diseases included in the pre- 1987 AIDS definition. Trends stratified by CD4+ cell count for the period 1990-1996 were substantially consistent with the above-reported results., Conclusions: The downward temporal trends in the most recent years of the study period for PCP and for brain toxoplasmosis are likely to be related to the use of prophylactic treatment. This analysis confirms a decline in KS but suggests that this was largely over by 1990.

Among 324 cases of culture-proven tuberculosis from 1988 to 1996 in a hospital in Milan, Italy, 90 (27.8%) were due to Mycobacterium tuberculosis strains resistant to isoniazid and rifampin. Sixty-one of 69 isolates tested had identical restriction fragment length polymorphism patterns. The prevalent strain tested susceptible only to ethionamide and was also resistant to ethambutol, streptomycin, cycloserine, amikacin, kanamycin, terizodone, ofloxacin, rifabutin, rifapentin, and KRM 1648. The median survival time was 94 days. Multivariate analysis showed a trend toward better outcome in the period 1994-1996 (hazard ratio, 4.16; P<.001), and extrapulmonary localization of tuberculosis was the only other independent predictor of a negative outcome (hazard ratio, 2.1; P = .019). The delay from symptoms to beginning of therapy did not seem to be a determining factor in survival time. Standard antituberculosis therapy with four drugs (isoniazid, rifampin, ethambutol, and pyrazinamide) had a higher efficacy than did other regimens with fewer drugs but without a statistically significant difference.

Aims: To define the potential risk factors, prognostic indicators, and quality of life of HIV-infected patients with enteric salmonellosis., Methods: A five-year matched (1:2) case-control study was performed. Thirty cases and 60 matched controls were studied., Results: Univariate analysis (p < 0.05) identified six risk factors for enteric salmonellosis: 1) increasing value of APACHE II score, 2) altered nutritional status, 3) previous antibiotic therapy, 4) ingestion of "risk" foods, 5) multiple (> or = 2) previous opportunistic infections, 6) stage C of HIV infection. Using the multivariate analysis, the most powerful predictors for developing an enteric salmonellosis were: increasing value of APACHE II score and altered nutritional status. The response to therapy was favourable in all episodes. Five (17%) patients suffered from one or more relapses. Multivariate analysis identified that a low number of circulating CD4+ (< 100/mm3) and a high APACHE II score (> 15) predict an increased risk of relapses., Conclusions: HIV-associated enteric salmonellosis occurs more frequently in patients with advanced stage of HIV infection and with impaired nutritional status. We stress the need for a prompt and accurate diagnosis and treatment since the possible haematogenous spread and relapses appear reduced under early and prolonged antibiotic therapy.

Mutations in a 69-bp region of the rpoB gene of Mycobacterium tuberculosis are associated with rifampin resistance (Rif[r]). These have been detected with mycobacterial DNA extracted from bacterial suspensions or respiratory specimens that were acid-fast smear positive. We experimented with a strategy for the rapid detection of Rif(r) in cerebrospinal fluid (CSF) samples. The strategy involves the amplification of the 69-bp region of rpoB by means of PCR and the identification of nucleotide mutations by single-strand conformation polymorphism (SSCP) analysis of the amplification products. Sixty-five CSF specimens collected from 29 patients (19 patients were coinfected with human immunodeficiency virus) with culture or autopsy-confirmed (22 patients) or highly probable (7 patients) tuberculosis of the central nervous system (CNS-TB) were processed. Amplified products suitable for evaluation by SSCP analysis were obtained from 37 CSF specimens from 25 subjects (86.2%). PCR-SSCP of CSF correctly identified the rifampin susceptibility phenotype of isolates from all 17 patients for whom the results of susceptibility tests carried out with strains cultured from CSF or respiratory samples were available. Moreover, this assay revealed the rifampin susceptibility genotype of isolates from the eight patients (three patients with culture-confirmed CNS-TB and five patients in whom CNS-TB was highly probable) for whom no susceptibility test results were available; the PCR-SSCP data obtained for these patients were concordant with the outcome after a standard antituberculosis treatment. The evolution of a mutation in the rpoB gene was documented in a patient during the course of treatment. PCR-SSCP analysis of CSF seems to be an efficacious method of predicting Rif(r) and would reduce the time required for susceptibility testing from approximately 4 to 8 weeks to a few days.

Background: The risk of developing active tuberculosis associated with a different size of induration to purified protein derivative (PPD) has not been prospectively assessed among individuals infected with human immunodeficiency virus (HIV). The quantification of this risk is important to more appropriately identify candidates for preventive therapy for tuberculosis., Methods: A prospective, multicenter, cohort study on tuberculosis in HIV-infected patients was conducted in 23 infectious disease units in public hospitals in Italy. Two thousand six hundred ninety-five HIV-infected patients were enrolled in the study. Of these, 1054 patients who were nonanergic at the time of entry were included in the present analysis. The median duration of follow-up was 102 weeks. The main outcome measure was a diagnosis of active tuberculosis confirmed by the isolation of Mycobacterium tuberculosis in culture., Results: Among the 252 patients with PPD reactivity, patients with an induration to PPD of 2 to 4 mm had a median CD4+ lymphocyte count of 0.34 x 10(9)/L (interquartile [IQ] range, 0.14 x 10(9)-0.56 x 10(9)), those with a response of 5 to 9 mm had a median count of 0.38 x 10(9)/L (IQ range, 0.24 x 10(9)-0.56 x 10(9)), and those with a response of 10 mm or higher had a median count of 0.37 x 10(9)/L (IQ range, 0.23 x 10(9)-0.52 x 10(9)) (P = .38). Compared with the 802 nonanergic PPD-negative patients, hazard ratios of tuberculosis were 2.1 (95% confidence interval [CI], 0.2-18.3) among the 55 patients with a response to PPD of 2 to 4 mm, 5.7 (95% CI, 1.6-19.8) among the 128 patients with a response to PPD of 5 to 9 mm, and 23.1 (95% CI, 7.8-68.6) among the 69 patients with a response to PPD of 10 mm or higher., Conclusions: Among nonanergic HIV-infected patients, the degree of response to tuberculin does not appear to reflect the degree of immunosuppression and is strongly correlated with the subsequent incidence of tuberculosis. To identify HIV-infected patients who are at an increased risk of tuberculosis and may benefit from preventive therapy, a response to PPD of 5 mm appears to be an appropriate cutoff point.

Immune system deficiencies, particularly cell-mediated immunity are the main events of HIV infection. The resulting syndrome is removies: AIDS. This immune deficiency encourages neoplasms such as the Kaposi sarcoma and non Hodgkin lymphoma, above all, it explains the reason why infections supported by opportunist germs, normally not pathogenic for immuno-competent people, are the main reason for morbidity and mortality in this kind of patients. Since among mycotic infections, the main one in these patients is candidiasis, particularly oro-pharyngeal candidiasis, we have carried out a research with the aim of evaluating the main mucosae oris pathologies in HIV and AIDS patients and, among them, the most directly correlated to HIV infection with reference to oro-pharyngeal candidiasis. We have based our research on the analysis of 237 patients case-histories. From January 1993 to December 1994 these patients have been examined at the Odontological Surgery by the "Centro San Luigi" for HIV-correlated pathologies researches and treatments (Istituto Scientifico Ospedale San Raffaele-Milano.

Fifty-eight patients with AIDS disease were studied with MR imaging in the aim of detecting the grade of brain involvement. The examinations were performed with a 1.5 Tesla magnet. Thirty-seven showed white matter lesion (63.5%), twenty-five patients showed cerebral atrophy (43%), in eight patients the MR appearance was consistent with toxoplasmosis infection (13.5%), two patients showed a linfoma (3.4%) and two patients micrococcosis (3.4%). Seventeen out of the thirty-seven patients with white matter disease showed focal well circumscribed lesion (46%), while twenty showed diffuse involvement. Between the twenty-five patients with cerebral atrophy, twelve showed a prevalence of the cortical involvement and eight a subcortical atrophy. In five patients a concomitant, cortical and subcortical atrophy was found. Between the eight patients with neurotoxolesion and two of them a widespread encephalitis picture. The MR appearance of the two limphomas was that of periventricular, space occupying, masses. In two patients with micrococcis a nodular aspect of leptomeningeal lesions was found.

Nocardiosis is a well-described infection in immunocompromised patients, and has been rarely documented in patients with AIDS. Nocardia asteroides is the most frequently isolated etiologic agent. Rare cases are due to N. brasiliensis and N. otitidiscaviarum. This work describes the first case of nocardiosis in Italy caused by N. otitidiscaviarum in an AIDS patient. A 31 year-old intravenous drug abuser with a diagnosis of full-blown AIDS, presented with high fever and lymphadenitis with a fistula draining copious purulent discharge. Broad-spectrum antibiotic therapy was initiated, but the patient did not shown any improvement. Direct examination of the pus revealed numerous gram positive rods. When cultured N. otitidiscavarium was isolated and identified by morphological and biochemical tests.

The incidence, aetiology and clinical significance of visceral mycoses in HIV-infected subjects were evaluated by a retrospective survey of the clinical and microbiological records of 237 consecutive AIDS patients followed-up since 1984. Seventy-four patients out of 237 (31.2%) (56 males, 18 females; 55 IV drug abusers, 7 heterosexuals, 6 homobisexuals, 3 blood recipients and 3 children with congenitally-acquired HIV infection) presented 77 different episodes of visceral fungal infection as a whole, represented by candidiasis in 56 cases (oesophageal 45, pulmonary 5, sepsis 2, eye involvement 2, endocarditis and invasive oropharyngeal infection in the remaining 2 patients), cryptococcosis in 17 cases (meningoencephalitis in all subjects, with disseminated infection in 11 of them), and aspergillosis in 4 cases (pulmonary 2, cerebral and cranio-facial in the remaining 2 patients). In 57 out of 74 patients (77%), visceral mycoses were diagnostic or concurrent with the diagnosis of AIDS. Fungal diseases, as a whole, showed a significantly higher incidence (p < 0.03) among drug abusers, whereas homobisexual men presented a significantly lower frequency (p < 0.001, chi-square test) than AIDS patients with other risk factors for HIV infection. The onset of cryptococcosis was significantly associated with the male sex (p < 0.005, Fisher exact test). All subjects suffering from a visceral mycosis were severely immunosuppressed, with a higher rate of neutropenia in patients developing Candida and Aspergillus spp. infection (23 out of 56 patients with visceral candidiasis and 3 out of 4 cases of aspergillosis had an absolute neutrophil count lower than 1500 cells/mm3), while a severe reduction in CD4+ lymphocyte count was more evident among patients with cryptococcosis (13 out of 17 patients had a CD4+ cell count lower than 50/mm3). After remission of the primary episode of fungal infection (obtained in 80.5% of cases), the incidence of relapse observed in a long follow-up period (mean time 57.6 +/- 39.2 weeks) was elevated both for patients with cryptococcosis (7 cases out of 17) and subjects with candidiasis (19 cases out of 53), with no significant difference among patients receiving a secondary prophylaxis or not (22 relapses observed in 53 patients treated with maintenance antifungals versus 4 episodes in 8 patients followed for a comparable mean time with no antimycotic treatment). Fifty-two out of 74 patients (70.3%) have died up to now; in 21 of them death was due to or associated with the visceral mycosis (cryptococcosis in 11 cases, candidiasis in 8, aspergillosis in 2).(ABSTRACT TRUNCATED AT 400 WORDS)

Objective: To evaluate the correlation between clinical and autopsy findings in 250 AIDS patients., Methods: Clinical and autopsy diagnoses of AIDS-defining diseases in 250 AIDS patients who died in Milan between May 1984 and February 1991 were compared., Results: Pneumocystis carinii (PCP) and oesophageal candidiasis were the most frequent clinical diagnoses, while cytomegalovirus (CMV) infection was observed in almost half of the autopsies. Forty-seven per cent of the diseases found at autopsy had not been diagnosed during life; CMV infection, mycoses, HIV-specific brain lesions, cerebral lymphomas and progressive multifocal leukoencephalopathy (PML) had a higher rate of non-diagnosis in life. CMV visceral infection accounted for the majority of the diseases not recognized in life. In contrast, clinically diagnosed PCP, oesophageal candidiasis and, to a lesser degree, brain toxoplasmosis were often not found at autopsy, possibly indicating a significant rate of recovery and prevention of relapse. Finally, bacterial pneumonia and sepsis, although not AIDS indicator diseases, were observed in approximately one-third of the autopsies., Conclusion: Considerable differences in the frequency and type of the AIDS-defining diseases diagnosed during life and at post mortem were found.

A sensitive, specific, and reproducible ELISA which incorporated an oocyst soluble antigen was used in order to detect specific Cryptosporidium immunoglobulins G and M in Italian HIV-positive patients. The soluble antigen was prepared from purified oocysts collected from experimentally infected calves. The serum working dilution was established at 1 in 50. Of parasitologically positive and HIV-positive patients, 95% showed specific IgG or IgM or both in their serum. Of HIV-positive patients, some of whom had diarrhoea of uncertain aetiology, 15.8% were found to have specific IgG. Both specific IgG and IgM were detected in the serum of an HIV-positive patient 1 year before the shedding of oocysts in the faeces. Sixteen (5.3%) of 300 presumed healthy people, positive for specific IgG, were all IgM-negative. Any significant cross-reactions with other parasitic infections were not observed. With a serum dilution greater than 1 in 25, only a low degree of positivity was observed with samples highly IgG-positive for Toxoplasma species. The ELISA showed a higher than expected prevalence of Cryptosporidium infection in Italian HIV-positive patients.

The HIV infection has resulted in a marked increase in the incidence of disease caused by non-tuberculous and tuberculous mycobacteria. Although tuberculosis, in spite of other mycobacterioses, should not be even regarded as a marker of AIDS, recent epidemiological data collected in many countries and in Italy, highlight the correlation between the risk of tbc and the risk of AIDS. Furthermore, the evaluation of AIDS patient with active tbc, shows often atypical clinical patterns (rare cavitation, miliary lesions being common), probably related to a different lung immunoreactions caused by HIV infection.