We report a measles outbreak in Sardinia, Italy, that originated in a cruise ship passenger. The outbreak showed extensive nosocomial transmission (44 of 80 cases). To minimize nosocomial transmission, health care facilities should ensure that susceptible health care workers are vaccinated against measles and should implement effective infection control procedures.

IntroductionWe report the case of a multiple drug interaction involving clozapine, antifungals and oral contraceptives, which resulted in an increased clozapine plasma level, pericarditis with pericardial effusion and eosinophilia in a young Caucasian woman. These symptoms and signs disappeared a few days after discontinuation of clozapine. At present, we are not aware of reports of clozapine–antifungals interaction, whereas there is only one other case report on the interaction between oral contraceptives and clozapine. The purpose of this case report is to show the risk of potentially serious adverse effects stemming from drug interactions involving medications routinely used in clinical practice.Case presentationA 29-year-old Caucasian woman diagnosed with a schizoaffective disorder was admitted to a psychiatric unit for acute psychosis (hallucinations, delusions and catatonic behavior). She denied smoking tobacco products and was on long-term oral contraceptives. During the first month of hospitalization she was treated with antipsychotics and for 1 week she took simultaneously fluconazole and miconazole gel, after being diagnosed with oral candidiasis. On the last day of antifungals treatment, 29 days after admission, clozapine was started with resolution of psychotic symptoms. After 3 weeks, her clozapine plasma level had increased to 542ng/mL and eosinophilia was observed. She complained of nausea, vomiting and palpitations; echocardiography showed echocardiographic abnormalities and pericardial effusion. Oral contraceptives were discontinued and after 1 week clozapine was interrupted, with a complete resolution of side effects and pericardial effusion within 4 days.ConclusionsClozapine is metabolized by cytochrome P450. The use of inhibitors or other substrates of cytochrome P450, such as antifungals and oral contraceptives, can cause long-lasting interactions and clozapine toxicity. The Naranjo algorithm shows clozapine is a definite cause of pericarditis (score 9) and both clozapine–antifungals and clozapine–contraceptives interactions resulted probable (score 5) in Drug Interaction Probability Scale. A good knowledge on drugs that act as substrates, inhibitors or inducers of cytochrome P450 is mandatory. When those drugs are used in patients taking clozapine, blood level monitoring of clozapine should be recommended, since a lower dose of clozapine might be required to prevent clozapine toxicity.

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The morphological and phenotypical features of multicellular complexes formed by follicular dendritic cells and lymphocytes (FDC-LC) isolated from human hyperplastic tonsils and adenoids are described. FDC-LC obtained with this procedure were morphologically and immuno-phenotypically heterogeneous. In one type of FDC-LC, probably obtained from germinal centers, the lymphocytes exhibited ultrastructural features of centroblasts and centrocytes. In a second type, likely derived from follicular mantles, the enclosed lymphocytes were small in size and characterized by a condensed chromatin pattern. Similar heterogeneity was observed by immuno-phenotypical analysis, which revealed a prevalence of IgD+, CD3-, MT2+ small lymphocytes in a high proportion of FDC-LC. Both types of FDC-LC contained desmoplakin immunoreactivity in a typical punctate pattern corresponding to intercellular junctions when tested with a specific antibody. These findings confirm the importance of FDC in maintaining the follicular structure and also suggest that the different zones forming lymphoid follicles (mantle zone and germinal center) are formed by lymphocytes gathered in single "domains" by cytoplasmic processes of FDC. These domains have strong resistance to mechanical stress, such as that used in isolation procedures. FDC-LC have also been maintained as organized multicellular clusters for short periods (more than 48 h) in agarose gel cultures.

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Introducción: La medición de la calidad de vida (CV) en el paciente oncológico permite establecer una percepción del individuo sobre su estado de salud - enfermedad y el tratamiento instaurado. El objetivo del presente estudio es analizar la influencia de la situación nutricional en la CV de los pacientes.Material y métodos: Se llevó a cabo un estudio transversal en el Hospital Ramón y Cajal en 53 pacientes oncológicos durante un periodo de 6 meses.A estos pacientes se les realizó la valoración global subjetiva (VGS), un recuerdo 24h de la ingesta del día anterior y se les administró el cuestionario European Organisation for Research and Treatment of Cancer quality of Life Questionnaire Core 30 (EORTC QLQ-C30). De estos 53 pacientes, 9 fueron excluidos debido a una incompleta cumplimentación del cuestionario EORTC QLQ C-30. De los 44 pacientes restantes, el 52,3% pertenecía al grupo de normonutridos sin riesgo (VGS A); el 27,3 % al grupo de pacientes en riesgo de desnutrición o desnutrición moderada (VGS B) y el 20,5% restantes al grupo de pacientes con grave desnutrición (VGS C)Resultados: Las escalas funcionales (funcionamiento físico, social, emocional y cognitivo) fueron las menos afectadas por la situación nutricional de los pacientes, con valor de p>0,05, mientras que la escala funcional o de rol (p 0,002), junto con la escala global de salud (p 0,049), así como los síntomas defatiga (p 0,011), náuseas y vómitos (p 0,004)y el ítem simple de pérdida de apetito (p 0,001) son las que mostraron una asociación estadísticamente significativa con la situación nutricional.Conclusiones: La desnutrición afecta negativamente a la CV de los pacientes oncológicos especialmente en las escalas de funcional, escala global de salud y de síntomas. Son necesarios más estudios para evaluar si la intervención nutricional precoz puede revertir esta influencia negativa de la desnutrición.

Dabigatran, a reversible direct thrombin inhibitor, is a new oral anticoagulant developed for long-term prevention of thromboembolic disorders whose safety profile is not completely known yet. Here we report a case of dabigatraninduced severe thrombocytopenia which was signaled to our Regional Center of Pharmacovigilance.An 84 year old Caucasian man started dabigatran due to a permanent atrial fibrillation. Five months later he was admitted to the emergency department following a skin eruption. Physical examination revealed a hemorrhagic necrotic skin lesion in the lumbosacral region. Blood tests showed a severe thrombocytopenia, with a platelet count of 16.000 mm3. The patient was hospitalized and dabigatran was promptly suspected to be the causative agent of thrombocytopenia, so the drug was discontinued and one week later platelet count completely normalized. Segmental distribution of the cutaneous lesions suggested hemorrhagic herpes zoster, so the patient was treated with oral valacyclovir and local gentamicin, with complete remission after a few months.To the best of our knowledge, severe thrombocytopenia induced by dabigatran has never been previously reported in literature, although the Italian National Pharmacovigilance database of the Italian Medicines Agency reports seven cases of thrombocytopenia associated with dabigatran, including ours. According to Naranjo algorithm severe thrombocytopenia was possibly due to dabigatran, which suggests a careful monitoring of patients being treated with this drug.