Shewanella putrefaciens is as yet rarely responsible for clinical syndromes in humans. However, a case involving multiple organs in an elderly male under treatment with appropriate steroids confirms that attention should be devoted to unusual pathogens. CASE REPORTAn 87-year-old Caucasian male who had come back a few days before from holidays on the Adriatic shore was admitted because of shivering, fever up to 39.8°C, and erysipelas of the left forearm. He complained of malaise, extreme weakness, and severe pain at the upper left extremity. No other relevant symptoms were present. There was a history of "rheumatic myalgia" (not well diagnosable) for which he was on long-term, low-dose methylprednisolone (4 mg once daily); he denied other previous illnesses of note and regular consumption of any drugs.On exam, he presented as an obese man with a typical Cushing-like face and was febrile (39°C) but hemodynamically stable. A 1.5-cm-long cutaneous-subcutaneous wound was present on the skin near the left elbow, together with erysipelas affecting the whole left forearm. Small-bubbled rattling noises were heard at the level of the left pulmonary basis. In view of the fever, immediate blood (three sets each in aerobic and anaerobic bottles) (BD BACTEC, Benex Ltd., Shannon, Ireland), urine, and stool cultures were taken. Wound exudate was not cultured, nor was skin biopsy performed. Hematological investigations revealed a white cell count of 13.9 ϫ 10 9 / liter, a hemoglobin level of 14.0 g/dl, and a platelet count of 167 ϫ 10 9 /liter. C-reactive protein was at 13.5 mg/dl (normal range, 0 to 0.5 mg/dl), and the erythrocyte sedimentation rate was 37 mm (normal range, 0 to 10 mm). Chest X-ray film showed a segmental infiltrate in the left lower lobe very close to the diaphragm muscle and consistent with pneumonia. No sputum cultures were obtained, and the stable general conditions of the patient suggested delaying a bronchoscopy in order to recover lung aspirate. The patient was given empirical antimicrobial therapy with intravenous

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SummaryThe rationale for exchange blood transfusion (ET) in severe falciparum malaria is threefold: reduction of parasitaemia, reduction of presumptive 'toxic' factors, and improvement of the rheological quality of the blood. We evaluated the records of 61 patients treated with ET to describe the present status of malaria treatment in Germany, Austria and Switzerland and to assess the efficacy of ET. Clinical data of 61 patients treated with ET were compared to data of 63 patients treated in 2 hospitals where ETs were generally not performed. We found that exchange transfusion is applied according to the clinician's subjective impression rather than strict guidelines. Logistic regression analysis adjusting for the differences in clinical parameters between patients treated with or without ET did not identify treatment as a prognostic indicator (odds ratio for relative risk of death with ET: 1.3; 95% CI: 0.4-4.9). Exchange transfusion did not significantly improve the unfavourable prognosis in cases of severe falciparum malaria. However, failure to reach statistical significance may be due to the retrospective design of the study and therefore non-systematic approach.keywords malaria, Plasmodium falciparum, treatment, exchange blood transfusion correspondence Dr Gerd-Dieter Burchard, Bernhard

SummaryBackgroundDrug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a rare and severe adverse drug reaction with an associated mortality of 10–20%. Clinical worsening despite discontinuation of the culprit drug is considered a characteristic feature of DIHS/DRESS. Besides the early recognition of the syndrome and discontinuation of its causative drug, the mainstay of treatment is systemic corticosteroids. Nevertheless, treatment of severe DIHS/DRESS is not well defined, as corticosteroids may sometimes not be effective, and decreasing the dose may be associated with flaring of the disease.Case ReportA 38-year-old woman with high fever, malaise, abdominal pain, rash, and elevated liver enzymes received immediate high-dose N-acetylcysteine, because acetaminophen hepatotoxicity was suspected. N-acetylcysteine administration was associated with a significant clinical improvement. However, within the next week DIHS/DRESS syndrome was diagnosed, which explained all the symptoms, and which was subsequently treated with prednisone and valganciclovir.ConclusionsNew options necessary to improve treatment of severe DIHD/DRESS have to consider its sequential pathogenetic mechanisms. N-acetylcysteine might neutralize the drug-derived reactive metabolites, which are responsible for protein adduct formation and specific T cell stimulation, and replete the glutathione stores that counterbalance oxidative stress. Prednisone might inhibit lymphoproliferation and valganciclovir might prevent complications related to HHV-6 reactivation. We therefore propose the unprecedented combination of N-acetylcysteine, prednisone and valganciclovir as a treatment option for DIHS/DRESS.

In 2012, we conducted a retrospective cross-sectional study to assess the number of people living with HIV linked to care and, among these, the number of people on antiretroviral therapy. The health authority in each of the 20 Italian Regions provided the list of Public Infectious Diseases Clinics providing antiretroviral therapy and monitoring people with HIV infection. We asked every Public Infectious Diseases Clinic to report the number of HIV-positive people diagnosed and linked to care and the number of those on antiretroviral therapy during 2012. In 2012, 94,146 people diagnosed with HIV and linked to care were reported. The majority were males (70.1%), Italians (84.4%), and aged between 25 and 49 years (63.4%); the probable route of transmission was heterosexual contact in 37.5% of cases, injecting drug use in 28.1%, and male-to-male contact in 27.9%. Among people in care, 20.1% had less than 350 CD4 cells/μl, 87.6% received antiretroviral therapy, and among these, 62.4% had a CD4 cell count higher than 350 cells/μl. The overall estimated prevalence of individuals diagnosed and linked to care in 2012 in Italy was 0.16 per 100 residents (all ages). Adding the estimated proportion of undiagnosed people, the estimated HIV prevalence would range between 0.19 and 0.26 per 100 residents. In Italy, the majority of people diagnosed and linked to care receive antiretroviral therapy. A higher prevalence of individuals diagnosed and linked to care was observed in Northern Italy and among males. More information for developing the HIV care continuum is necessary to improve the entire engagement in care, focusing on test-and-treat strategies to substantially reduce the proportion of people still undiagnosed or with a detectable viral load.