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BACKGROUND. We report the preliminary observation of community acquired brain abscess in immunocompetent adult patients early treated with high penetrating oral antibiotics, even without microbiological isolation, that showed good outcome. METHODS. A retrospective analysis of eight patients being managed for brain abscess who underwent early oral antimicrobial therapy is reported. Data collected of age, sex, co-morbidity, risk factors, diameter of the abscess, microbiological findings, management of therapy, focusing on its early shift to oral regimen and outcome after one year of follow-up. RESULTS. Two of eight patients, with a mean age of 59,3 years, required neurosurgery, in 3 case we found positive microbiological samples. The medium length from initial i.v. therapy to per os regimen was 7,7 and the medial length of the complete course of therapy was 58 days. Most of them received the same empiric antimicrobial therapy with levofloxacin and linezolid, because of their high oral bioavailability and optimal penetration into brain barrier. All the patients had clinical improvement and showed no signs of persistent cerebral abscess at one year of follow-up. CONCLUSIONS. Cerebral abscess is a significant cause of morbidity and mortality, nevertheless, in selected cases, it can be treated with antimicrobial therapy per os, even in case of negative microbiological samples. Oral antimicrobial therapy could be non inferior to intravenous antibiotic therapy, moreover it has advantages reducing time of hospital stay and improving quality of life and patient compliance to long period of antimicrobial treatment.

Pediatric 2019 novel coronavirus disease (COVID-19) is characterized by a wide clinical spectrum, including hematological manifestations.1 Anemia and thrombocytopenia occur mainly in severe forms of the disease and in multisystem inflammatory syndrome2 but are rare in asymptomatic and mildly symptomatic patients. Only few reports of autoimmune hemolytic anemia (AIHA), rarely associated with immune thrombocytopenia (ITP), have been described in children with COVID-19.3–5 Here, we present two pediatric cases of severe cold agglutinin disease and a brief review of the literature

Objectives: We aimed to develop and validate a risk score to predict severe respiratory failure (SRF) among patients hospitalized with coronavirus disease-2019 (COVID-19). Methods: We performed a multicentre cohort study among hospitalized (>24 hours) patients diagnosed with COVID-19 from 22 February to 3 April 2020, at 11 Italian hospitals. Patients were divided into derivation and validation cohorts according to random sorting of hospitals. SRF was assessed from admission to hospital discharge and was defined as: SpO2 30 breaths/min or respiratory distress. Multivariable logistic regression models were built to identify predictors of SRF, β-coefficients were used to develop a risk score. Trial Registration NCT04316949. Results: We analysed 1113 patients (644 derivation, 469 validation cohort). Mean (±SD) age was 65.7 (±15) years, 704 (63.3%) were male. SRF occurred in 189/644 (29%) and 187/469 (40%) patients in the derivation and validation cohorts, respectively. At multivariate analysis, risk factors for SRF in the derivation cohort assessed at hospitalization were age ≥70 years (OR 2.74; 95% CI 1.66–4.50), obesity (OR 4.62; 95% CI 2.78–7.70), body temperature ≥38°C (OR 1.73; 95% CI 1.30–2.29), respiratory rate ≥22 breaths/min (OR 3.75; 95% CI 2.01–7.01), lymphocytes ≤900 cells/mm3 (OR 2.69; 95% CI 1.60–4.51), creatinine ≥1 mg/dL (OR 2.38; 95% CI 1.59–3.56), C-reactive protein ≥10 mg/dL (OR 5.91; 95% CI 4.88–7.17) and lactate dehydrogenase ≥350 IU/L (OR 2.39; 95% CI 1.11–5.11). Assigning points to each variable, an individual risk score (PREDI-CO score) was obtained. Area under the receiver-operator curve was 0.89 (0.86–0.92). At a score of >3, sensitivity, specificity, and positive and negative predictive values were 71.6% (65%–79%), 89.1% (86%–92%), 74% (67%–80%) and 89% (85%–91%), respectively. PREDI-CO score showed similar prognostic ability in the validation cohort: area under the receiver-operator curve 0.85 (0.81–0.88). At a score of >3, sensitivity, specificity, and positive and negative predictive values were 80% (73%–85%), 76% (70%–81%), 69% (60%–74%) and 85% (80%–89%), respectively. Conclusion: PREDI-CO score can be useful to allocate resources and prioritize treatments during the COVID-19 pandemic.

A 62-year-old man presented to the Emergency Department of Sant'Orsola-Malpighi University Hospital in Bologna, Italy, because of a rapidly progressive cognitive decline. He had recently come back to Italy after a 3-month journey in Brazil because relatives found him confused while speaking over the phone. Because of global slowing, disorientation, and confabulation, which developed over the previous 2 months, he underwent a brain MRI in Brazil, which showed cortical atrophy and multiple white matter lesions with no contrast enhancement. No further clinical information about the medical assessment in Brazil was available.

Introduction: Prostate cancer is a very infrequent occurrence in persons aged 55 years or less, and it has been rarely reported in HIV-infected patients (10 overall cases so far); therefore, an increased incidence compared with the general population has not been established, although a younger age seems more frequent among population with HIV disease. Case report: We report a case of metastatic prostate cancer occurred in a 53-year-old HIV-infected man, admitted due to non-specific signs, and symptoms: impaired general conditions, fever, weight loss, fatigue, and exertional dyspnea. A remarkable anemia and an aortic systolic murmur were the prominent initial findings, while AIDS-related conditions were not suspected due to a sustained CD4+ count and a contained viremia, which never required antiretroviral therapy. Repeated red blood cell transfusions and an empiric, combined antimicrobial therapy were promptly carried out, under the suspicion of infectious endocarditis, but no appreciable improvement of clinical conditions was achieved. Subsequently, our patient complained not only of an increasingly severe pain at the root of his left thigh, together with overcoming dysuria and urgency, but also urinary tract infection that was rapidly ruled out. During the diagnostic workup for an HIV-associated fever of undetermined origin, a bone marrow biopsy disclosed a metastatic prostatic cancer, with elevated prostate specific antigen (PSA) and acid phosphate levels. An abdominal–pelvic ultrasonography and computerized tomographic scan allowed to detect a dyshomogeneous endopelvic expansive mass with extrinsic compression of the urinary bladder, and involvement of the last lumbar vertebra, large portions of pelvis, and the proximal epiphysis of the right femur. A skeleton scintigraphy pointed out multiple hypercaptation (areas of concentrated traces of radioactivity) areas with involvement of cranial, cervical, dorsal, lumbar, and sacral vertebrae, as well as the pelvis and upper portions of both femurs. Despite therapeutic attempts, our patient deceased after seven weeks due to an overwhelming disseminated intravascular coagulation (DIC). Conclusions: The non-specific clinical presentation of our case (mimicking other generalized or focal illnesses), and the final, lethal complication (DIC) pose striking problems related to the differential diagnosis during HIV disease, while the rapid evolution into an advanced, complicated, and widely metastatic disease with extensive bone marrow invasion which preceded the appearance of local signs–symptoms, and the lethal overwhelming DIC, deserves attention by specialists who care for HIV-infected subjects.

We report a case of spontaneous clearance of hepatitis C virus (HCV) in a patient co-infected for 20 years with HCV and HIV, and with an chronic active hepatitis C never treated with anti-HCV regimens. We review the literature of eight anecdotal reports describing the spontaneous resolution of chronic HCV infection among HIV-infected patients, and discuss the virological, immunological, pathogenetic and therapeutic implications of this observation.

A significant case report of a HIV infected patient in his fifties who experienced an excellent virological and immunological response to antiretroviral therapy (which has been modified just to prevent or avoid some adverse events), but developed a severe, sudden acute kidney failure while under a polypharmacy due to some underlying and overwhelming disorders (i.e. arterial hypertension, non-insulin-dependent diabetes mellitus, a recent acute heart infarction with remarkable remnants, and finally an anecdotal muscle-joint pain with self-prescription of non-steroideal anti-inflammatory drugs), represents the key point for a debate around the increasing frequency of “polypharmacy” in the field of HIV infection, even when HIV resistance to antiretroviral is not a concern. The continuing increase of mean age of HIV-infected population, plus the existing, sometimes unmodifiable risk factors for cardiovascular, dysmetabolic, and renal disorders, plus the adjunct of anecdotal illnesses prompting the resort to different drugs and medications, either prescribed for HIV infection itself, or taken for concurrent or subsequent diseases, or self-prescribed occasionally due to an intercurrent, trivial disorders per se, may prompt a complicated scenario culminating with a life-threatening acute renal failure of tubular origin. Our report gives us the opportunity to revise and discuss the expected interactions between antiretroviral therapy and the even growing exposure to multiple different drug and drug classes, which may be responsible for relevant drug interactions and direct or adjunctive end-organ impairment, up to life-threatening conditions, which may be avoided or prevented by considering carefully all comorbidites and co-treatments potentially administered to HIV infected patients, thirty years after the discovery of AIDS.

An exemplary case report of dual-site, respiratory and genito-urinary granulomatous infection caused by bacillus of Calmette-Guerin (BCG) in a patient with prior pulmonary tuberculosis and with chronic obstructive pulmonary disease (COPD), treated for several weeks with local, intravesical adjuvant BCG therapy for a relapsing transitional bladder carcinoma, is presented and discussed in the context of the cumbersome diagnostic and differential diagnostic process, as well as recent findings in the literature. Only four cases of respiratory BCG-itis (tuberculosis-like forms) have been reported until now to the best of our knowledge (two of them following bladder instillation of BCG), but our case is the only one which showed a dual, concurrent granulomatous localization of BCG-itis, also involving the genito-urinary tract.

Background Aim of our work is to present two exemplary cases of patients (p) who received a prolonged intravesical immunotherapy with instillations of Bacillus of Calmette-Guerin (BCG), to treat an urothelial carcinoma of the bladder relapsing after endoscopic-surgical treatment, who suffered from a severe pulmonary infection caused by Mycobacterium bovis. Their diagnostic pathway was particularly cumbersome due to the co-existing chronic pulmonary diseases (COPD), and prior respiratory disorders (including a juvenile tuberculosis). The second presented p was also interested by a genito-urinary (penile) localization of BCG infection, to attribute to local BCG dissemination.

Results Until this last semester, against medical recommendation, our p continued alcohol consumption and irregular drug addict, despite an ongoing methadone program. Serum transaminases showed fluctuating values, always >2-3.5-fold normal levels, while HCV replication was confirmed by values of 1,200-4,000 × 10 IU/mL. During the last 6 months, our p first abandoned its former lamivudine-zidovudine-nevirapine therapy, leading to a combination including 2 novel nucleos(t)ide analogues (tenofovir-emtricitabine), associated to the protease inhibitors (PI) lopinavir-ritonavir, and finally in the last 3 months due to gastrointestinal intolerance-hypertriglyceridemia he introduced fosamprenavir-ritonavir on behalf of lopinavir-ritonavir. Already after lopinavir-ritonavir use, our p attained undetectable plasma HIV-RNA levels (always confirmed thereafter), while CD4+ count showed the greatest values even registered by our p (513-662 cells/μL). During 2 subsequent controls, qualitative HCV viremia tested negative for the first time, concurrently with normal transaminases.

Two (2) exemplary case reports of respiratory granulomatous infection caused by Bacillus of Calmette-Guerin (BCG), in patients who were repeatedly treated with local, intravesical adjuvant BCG therapy for a relapsing transitional bladder carcinoma, are outlined and discussed on the grounds of the cumbersome diagnostic and differential diagnostic process (especially when a prior tuberculosis and a concurrent chronic obstructive pulmonary disease are of concern), along with an updated literature revision. Only 4 cases of respiratory BCG-itis (pulmonary tuberculosis-like forms) have been reported, to date, to the best of our knowledge (2 of them following the bladder instillation of BCG). One (1) episode of ours represents the first described case with a dual, concomitant granulomatous localization of BCG-itis, also involving the genitourinary tract.

When evaluating the tolerability profile of interferons, the authors focus their attention on peripheral neuropathy, by assessing the epidemiological, pathogenetic, clinical, and outcome aspects, in relation with the administration of these drugs and the concurrent increase of risk factors associated with underlying diseases (including chronic viral hepatitis, solid organ malignancies, hematological disorders, autoimmune diseases, HIV infection). Even though it is often impossible to exclude a direct or indirect interferon-associated pathogenetic pathways in the occurrence of peripheral neuropathies, predominatly through immune-mediated mechanisms, the episodes reported by the international literature are steadily on the rise, paralleling the enlargement of therapeutic indications, and the availability of novel interferon formulations for clinical use. The increased indications of interferons in a broadening spectrum of clinical disorders, and especially their use in chronic hepatitis, recommend a strict monitoring of all possible adverse events, in order to reach a better epidemiological, pathogenetic, and clinical awareness of clinical events which are still infrequent, but potentially severe, such as those involving the peripheral nervous system.

1. Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 2. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Prostate cancer is a very infrequent occurrence in persons aged 55 years or less, and it has been rarely reported in HIV-infected patients (10 overall cases so far); therefore, an increased incidence compared with the general population has not been established, although a younger age seems more frequent among population with HIV disease.We report a case of metastatic prostate cancer occurred in a 53-year-old HIV-infected man, admitted due to non-specific signs, and symptoms: impaired general conditions, fever, weight loss, fatigue, and exertional dyspnea. A remarkable anemia and an aortic systolic murmur were the prominent initial findings, while AIDS-related conditions were not suspected due to a sustained CD4+ count and a contained viremia, which never required antiretroviral therapy. Repeated red blood cell transfusions and an empiric, combined antimicrobial therapy were promptly carried out, under the suspicion of infectious endocarditis, but no appreciable improvement of clinical conditions was achieved. Subsequently, our patient complained not only of an increasingly severe pain at the root of his left thigh, together with overcoming dysuria and urgency, but also urinary tract infection that was rapidly ruled out. During the diagnostic workup for an HIV-associated fever of undetermined origin, a bone marrow biopsy disclosed a metastatic prostatic cancer, with elevated prostate specific antigen (PSA) and acid phosphate levels. An abdominal-pelvic ultrasonography and computerized tomographic scan allowed to detect a dyshomogeneous endopelvic expansive mass with extrinsic compression of the urinary bladder, and involvement of the last lumbar vertebra, large portions of pelvis, and the proximal epiphysis of the right femur. A skeleton scintigraphy pointed out multiple hypercaptation (areas of concentrated traces of radioactivity) areas with involvement of cranial, cervical, dorsal, lumbar, and sacral vertebrae, as well as the pelvis and upper portions of both femurs. Despite therapeutic attempts, our patient deceased after seven weeks due to an overwhelming disseminated intravascular coagulation (DIC).The non-specific clinical presentation of our case (mimicking other generalized or focal illnesses), and the final, lethal complication (DIC) pose striking problems related to the differential diagnosis during HIV disease, while the rapid evolution into an advanced, complicated, and widely metastatic disease with extensive bone marrow invasion which preceded the appearance of local signs-symptoms, and the lethal overwhelming DIC, deserves attention by specialists who care for HIV-infected subjects.

Common variable immunodeficiency with an associated broad immunoglobulin (0.7%) deficit affecting all subclasses, was revealed in a 27-y-old previously healthy female, upon development of a severe pneumococcal meningitis. We report the third case of purulent meningitis complicating this primary immunodeficiency, and the second due to Streptococcus pneumoniae. Clinicians should maintain an elevated suspicion for congenital immunodeficiency, especially when observing adult patients with a negligible prior history.

The Authors describe two cases of HIV patients treated with Protease Inhibitors that have gone on to suffer from lipodystrophy, metabolic disorder, diabetes and myocardial infarction (fatal in one of them). The surviving patient underwent a Percutaneous Transluminal Coronary Angioplasty (PTCA) with improvement of the acute coronary syndrome. In the light of the review of literature and our observations, we propose some considerations about prevention, diagnostic and therapeutic management of HIV patients treated with IP and cardiovascular risk.

The incidence of Hodgkin's disease appears to progressively increase in human immunodeficiency virus (HIV)-infected patients, with the relative risk of developing this malignancy rising from the early phase to the advanced stage of HIV disease. Clinical and pathological features of Hodgkin's lymphoma in HIV-positive subjects differ from those of the general population, showing a higher frequency of unfavourable histological subtypes, advanced stage with frequent extranodal involvement at initial diagnosis, and a poor therapeutic outcome. The optimal therapeutic strategy is still controversial, and median overall survival is short, ranging from 12 to 18 months. In this report, cases of Hodgkin's disease are described among over 1000 HIV-infected patients referring to a tertiary care centre during a 6 y study period.

By using abdominal ultrasonography (UlS), deep nodes were detected in 41 of 85 (48%) HIV-1 positive subjects, most of them heroin addicts, but in none of 85 healthy HIV-negative controls. Computerized tomography, performed in 10 cases of lymphadenopathy, invariably confirmed the UlS findings. Prevalence [asymptomatic carriers: 8/15 (53%); PGL patients: 8/18 (44%); ARC: 13/27 (48%); AIDS: 12/25 (48%)], number, size, and site of deep nodes were comparable among the different CDC groups. No correlation was found between abdominal and superficial lymphadenopathy. Median serum concentrations of gammaglobulins (g/dl) and IgG (mg/dl) were higher in patients with than without deep nodes (2.25 vs 1.87 and 2540 vs 1900, respectively) (p0.01) as well as in cases with than without superficial nodes (2.15 vs 1.80 and 2340 vs 1941, respectively) (p0.05). Abdominal lymphadenopathy occurred during all stages of HIV infection even in asymptomatic carriers: this should be considered in the differential diagnosis of UlS-detected deep nodes. Enlargement of either deep or superficial nodes seems to reflect a state of polyclonal B cell activation.

A case of cervicofacial and pulmonary actinomycosis associated with non-Hodgkin's lymphoma (NHL) is reported. The patient underwent antimicrobial treatment and surgical debridement of a palatine lesion. Complete clinical recovery was achieved. The presence of actinomycosis may obscure and delay the diagnosis of NHL.

We report the uncommon case of an acute cavernous sinus syndrome in a patient who was consequently discovered to have both a cavernous internal carotid artery aneurysm and bacterial meningitis. Which came first, the chicken or the egg? Which of the two, the aneurysm or the meningitis, gave rise to the patient’s symptoms? We briefly reviewed the literature of similar cases and tried to analyze the possible pathophysiological relationship between these findings. Moreover, this case highlights the importance of a multidisciplinary management of these patients to better decide between a medical and a surgical and/or endovascular treatment.