Maurizio Gulletta

To evaluate the usefulness of a real-time PCR for Leishmania DNA in the diagnosis and follow-up of patients with human immunodeficiency virus type 1 (HIV-1) and Leishmania coinfection, Leishmania DNA levels were measured in whole peripheral blood from 25 HIV-infected patients with clinical features suggestive of visceral leishmaniasis. Leishmania DNA was detected in 10 of 25 patients with microscopically confirmed visceral leishmaniasis and in none of those without this disease. Following treatment with liposomal amphotericin B, a clinical response was observed in 9 of 10 patients, in association with significantly decreased parasite loads. Seven patients relapsed clinically a median of 110 days after the end of treatment, in association with substantial increases in Leishmania DNA levels. Leishmania DNA levels correlated with the clinical course of visceral leishmaniasis, and their measurement at diagnosis and during and after treatment seems to be useful in the clinical management of HIV-infected patients with this disease.

To the Editor: Chikungunya virus (CHIKV) infection is a self-limiting illness characterized by fever, headache, weakness, rash, and arthralgia. Some patients have prolonged weakness or arthralgia lasting several months. In 2006, several Indian Ocean states and India had an outbreak of CHIKV infection (1,2). During the epidemic’s peak, some European and American travelers returning from these areas were infected (3–6). Because the foci of Aedes albopictus, 1 of the 2 main vectors of CHIKV, are now in Italy and many travelers visit CHIKV-epidemic areas, surveillance for imported cases is mandatory in Italy (7). From July to September 2006, a total of 17 confirmed cases of CHIKV infection were observed in travelers at 5 Gruppo di Interesse e Studio delle Patologie di Importazione (GISPI) centers (Italian network of Institutes of Infectious and Tropical Diseases). Serologic diagnosis was performed with a hemagglutination-inhibition test and confirmed by a plaque-reduction neutralization test (8). Demographic and epidemiologic characteristics of these patients are reported in the Table. Table Demographic and epidemiologic data on 17 travelers with chikungunya infection diagnosed in 2006, Italy Cases were distributed throughout the year with a peak from March to May 2006 (n = 10). Nine patients (53%) were men. Median age was 43 years (range 31–66 years). Several reasons for travel were reported: tourism (64.6%), visits to relatives or friends (11.8%), business (11.8%), and missionary work (5.9%). One patient was a resident in the disease-epidemic area. The median exposure time in the CHIKV-endemic area for the 15 travelers was 15 days (range 9–93 days) (missionary and resident patients were excluded). The median delay before being seen at a clinic after return was 2 days (range 0–73 days). Only 7 patients (41.2%) were hospitalized. The remainder were outpatients. All patients had fever; arthralgia (88.2%, n = 15), weakness (70.6%, n = 12), headache (11.8%, n = 2), diarrhea (11.8%, n = 2), and gum bleeding and epistaxis (5.9%, n = 1) were other reported symptoms. The median duration of fever was 5 days (range 2–12 days). Only 7 of 16 patients (43.8%) were still febrile when first seen. Physical examination showed diffuse macular erythematous rash in 13 patients (76.5%), a similar rate to that reported among French travelers (4). Hepatomegaly was found in 2 patients (11.8%), splenomegaly in 2 (11.8%), and peripheral lymphadenopathy in 2 (11.8%). Twelve acute-phase patients were admitted to the hospital for blood testing within 3 days of the initial examination. In contrast with results of other studies, leukopenia and thrombocytopenia were uncommon in our study. Leukopenia (leukocyte count 40 IU/L) in 5 (41.7%) and 2 (16.7%) patients, respectively. Seven (46.7%) of 15 patients fully recovered within 1 month; 8 patients (53.3%) reported persistent arthralgia. Because the GISPI network provides regional coverage only, the number of imported CHIKV cases in all of Italy in 2006 was likely higher. Moreover, most patients probably did not seek medical care, and when they did, physicians may have failed to recognize the disease because of lack of familiarity with it or limited diagnostic facilities. Differential diagnosis with other arthropodborne viruses of the Alphavirus genus (Ross River, Barmah Forest, o’nyong nyong, Sindbis, and Mayaro viruses) is difficult, but these are comparatively rare. In contrast, dengue and CHIKV epidemics may overlap, and potential patients should be screened for both. The potential risk for introduction and establishment of CHIKV reservoirs in areas with mosquito vectors was discussed in March 2006 by a multidisciplinary European expert panel (9). In Italy, A. albopictus was first recorded in 1990; it has since quickly spread across the country. Scattered foci are now reported in almost all regions, mainly along the coastal plains, from the sea to the inlands, up to an altitude of ≈500–600 m (7). The ability of A. albopictus to colonize new areas and its adaptability to the mild Italian climate allow vector populations to be active throughout the year (10). The patient is thought to be viremic for only 6–7 days (shortly before and during the febrile period) (6). We were unable to directly assess viremia levels; however, almost half the patients were still febrile on return to Italy, which suggests a potential risk. Although the same mosquito is a potential vector of dengue, no autochthonous case has been reported as yet, despite annual reports of many imported dengue cases in Italy. On the other hand, the clinical manifestations of both conditions are nonspecific, and a hypothetical autochthonous case would most likely go undiagnosed unless a targeted surveillance system were established. Prompt reporting of imported CHIKV infections is essential for monitoring of potential risk. The possibility of introducing CHIKV into Italy cannot be ruled out on the basis of current evidence.

BACKGROUND: SARS-CoV-2 pandemic has posed formidable public health and clinical challenges. The use of immunosuppressive agents, such as high dose corticosteroids and cytokine inhibitors (e.g., Tocilizumab) has been suggested to contrast the hyperinflammatory process involved in the pathogenesis of the severe disease, with conflicting evidence. Among the drawbacks of immunosuppressive therapy, the risk of reactivation of latent infections, including parasitic infestations, is to be considered. CASE PRESENTATION: We report a case of a 59-year-old Italian patient treated with high dose intravenous dexamethasone and two intravenous doses of Tocilizumab for interstitial bilateral pneumonia associated with SARS-CoV-2 infection who developed itching, abdominal pain, and an increased eosinophil count. Stool examination confirmed the presence of S. stercoralis larvae. The patient was treated with a 4-day course of Ivermectin with full recovery. DISCUSSION: We report the first case of S. stercoralis infection following an 11-day treatment with high-dose steroids and Tocilizumab for severe COVID-19. Clinicians should be aware of the risk of strongyloidiasis as a complication of the treatment for severe COVID-19.

Soil-transmitted helminth (STH) infections represent a major public health problem in poor and developing countries. During the period September-October 1998 we conducted an epidemiological survey of STH infections in schoolchildren of an urban area (group A) and an indigenous reserve (group B), in the Municipality of Ortigueira, State of Paranà, Brazil, to assess potential benefits of mass treatment. Stool samples were examined for helminth eggs by quantitative (Kato-Katz) technique to determine the prevalence and intensity of intestinal parasitic infection. Moreover, we examined the relationship between prevalence and intensity of STH infections and housing/hygienic factors (by means of a 7-item questionnaire). 236 schoolchildren aged 5-15 years were enrolled, 136 in group A and 100 in group B. The prevalence of STH infections was significantly higher in group B (93%) than in group A (22%) (P < 0.001). Detected parasites were: A. lumbricoides (16.1% prevalence in group A, 88% in group B, P < 0.001), hookworms (5.8% in group A, 52% in group B, P < 0.001) and T. trichiura (5.1% in group A, 2% in group B, P = 0.2). Heavy infections were detected in 2.9% and 23% of the children in group A and B, respectively (P < 0.001). Housing/hygienic indicators were significantly poorer in group B. A statistically significant correlation was observed between total prevalence of STH infections and prevalence of high-intensity infections with most housing/hygienic variables. On the basis of these results, mass treatment and educational interventions were suggested for the indigenous community, whereas target treatment and educational interventions were suggested for the urban community. Even in a geographically homogeneous area different epidemiological realities can be found, which in turn can influence infection levels and control programmes.