Verdiana Zulian

Introduction: Hepatitis E virus (HEV) infection is increasingly recognized as a cause of extrahepatic manifestations; however, cutaneous purpuric manifestations are exceptionally rare, with only one previous case of Henoch–Schönlein purpura (HSP) reported in association with acute HEV infection. Methods: This study describes the case of a 91-year-old man admitted with palpable purpura of the lower limbs, associated with jaundice, hypertransaminasemia, and cholestatic abnormalities. Molecular and serological assays were performed. Results: Serological testing showed anti-HEV IgM and IgG positivity, and HEV RNA was detected in plasma at a viral load of 15,002 IU/mL. The patient reported consumption of wild-boar meat in the month preceding symptom onset. The purpura resolved spontaneously approximately 10 days after onset, and liver parameters progressively improved, with HEV RNA becoming undetectable at follow-up. Phylogenetic analysis of the patient-derived sequence identified the strain as HEV genotype 3f, belonging to the 3f2 subcluster. The patient-derived sequence showed similarity with European HEV-3f/3f2 human strains and with swine and wild boar strains, supporting a likely zoonotic food-borne origin. Plasma interleukin-6 (IL-6) was elevated at admission during the purpuric manifestation. Discussion: To our knowledge, this is the first Italian report of an HSP-like purpura temporally associated with acute HEV genotype 3f infection. This case highlights that acute HEV infection may be considered in the differential diagnosis of patients presenting with palpable purpura, while emphasizing the exceptional rarity of this manifestation.

Laboratory-acquired infections (LAIs) and accidental pathogen escape from laboratory settings (APELS) are still a significant concern, even with biosafety guidelines and manuals in place. The actual number of these events is probably underestimated because there are no mandatory reporting systems or standard surveillance frameworks. In this review, a clear overview is given about the evolution of biosafety, the worldwide distribution and governance of high-containment laboratories (BSL-3 and BSL-4), and the key factors that lead to laboratory incidents. The focus is specifically on human error, inadequate training, and differences in standard operating procedures as primary causes of biosafety failures. Furthermore, current regulatory frameworks are described, pointing out the lack of consistency in laboratory practices, infrastructure needs, and national policies, especially the variances in biosafety level recommendations for high-risk pathogens. Certification systems as potential tools to improve standardization and consistency in operations are discussed. Among these, ISO 35001 is a detailed standard for managing biorisks, including risk assessment, staff training, incident reporting, and processes for ongoing improvement. However, its use is still limited, and certification is not mandatory for laboratory licensing everywhere. Additionally, existing standards do not fully cover structural aspects and national differences in how pathogens are handled. This review also highlights the limitations of current certification systems and proposes recommendations to strengthen and harmonize standardization procedures across high-containment laboratories. Overall, this work highlights the need for greater global consistency in biosafety practices, suggesting the establishment of an independent international auditing body as an important step toward enhancing global health security and laboratory readiness.

Background/Objectives: Oral human papillomavirus (HPV) infection is emerging as a key driver of HPV-associated oropharyngeal cancer, especially in high-risk groups such as men who have sex with men (MSM) living with HIV (PLWH). However, evidence on oral HPV persistence and the impact of nine-valent HPV vaccination in adults remains limited. We conducted a prospective longitudinal study including 76 MSM PLWH, of whom 64 were nine-valent HPV-vaccinated and 12 unvaccinated. Methods: Oral rinse samples were collected at baseline (T0) and after 6 months (T6). HPV DNA detection and genotyping were performed using the Allplex™ HPV28 assay. Oral HPV dynamics (persistence, clearance, and incidence) were assessed for high-risk (HR) HPV, low-risk (LR) HPV, and vaccine-type HPV genotypes. Results: Baseline oral HPV prevalence was high (59.2%), with HR HPV detected in 43.4% of participants. HPV16 was the most frequent genotype at both T0 and T6. Among participants HPV-positive at baseline, persistence of HPV DNA was high and similar regardless of vaccination status (77.8%). However, incident vaccine-type oral HPV infection was significantly lower among vaccinated individuals than unvaccinated participants (6.3% vs. 33.3%; OR 0.13, 95% CI: 0.03–0.71; p = 0.0441). Finally, reporting ≥10 sexual partners in the previous year was significantly associated with baseline oral HPV positivity (p = 0.0298). Conclusions: In MSM PLWH, oral HPV infection is highly prevalent and persistent, underscoring that it may represent a reservoir for HPV-related oropharyngeal disease. In our small observational cohort, nine-valent HPV vaccination was associated with lower incident detection of vaccine-type oral HPV, supporting targeted vaccination and oral HPV surveillance in high-risk adult populations, while highlighting the need for larger longitudinal studies to confirm these findings and better define the magnitude and durability of vaccine-associated protection at the oral site.

Chronic hepatitis delta is the most severe form of viral hepatitis and is associated with rapid progression to cirrhosis and hepatocellular carcinoma. Although bulevirtide (BLV) effectively inhibits hepatitis D virus (HDV) entry, immunological biomarkers reflecting treatment response and residual viral activity remain poorly defined. This study investigated the serum profiles of interleukin-37 (IL-37) and IL-36 isoforms (IL-36α, IL-36β, and IL-36γ) in 22 HBV/HDV-coinfected patients receiving BLV monotherapy (2 mg/day). Serum cytokine levels were measured by ELISA at baseline (BL) and after 48 weeks of BLV treatment (TW48) and compared with HBV-monoinfected patients under nucleos(t)ide-analogue therapy and healthy donors. Patients were stratified according to virological, biochemical, and combined responses. At both BL and TW48, serum IL-37, IL-36α, and IL-36β levels were significantly higher in HBV/HDV-coinfected patients than in comparison groups (all p < 0.05), independent of treatment response, indicating a persistent cytokine signature during BLV therapy. IL-36β levels significantly decreased over time, particularly in biochemical non-responders (p = 0.0469), whereas IL-36α remained elevated and differed at TW48 between combined responders and non-responders (p = 0.0400). IL-36γ was detectable only in a small subset of patients. Notably, in a subgroup of patients evaluated at week 96, baseline IL-37 levels were significantly lower in those achieving virological response compared with non-responders (p = 0.0275). Moreover, IL-37 was the only cytokine showing a significant positive correlation with HDV RNA levels at TW48 when quantified by the AltoStar^® assay (p = 0.033; R² = 0.7563). Overall, HBV/HDV-coinfected patients display a distinct IL-37/IL-36 cytokine profile during BLV therapy. The association between IL-37 and residual viremia supports further investigation of this cytokine as a complementary biomarker for monitoring low-level viral activity during treatment.

Persistent infection with high-risk human papillomavirus (HPV), particularly genotype 16, is the main driver of anogenital and oropharyngeal cancers. However, data on HPV16 genetic variability in anal and oral samples from people living with HIV are limited. In this study, we investigated the diversity of HPV16 E6 and E7 genes in anal and oral samples collected from HIV-positive men who have sex with men (MSM) according to different cytological outcomes and anatomical site. Among 53 MSM patients, we obtained 51 E6 and 52 E7 sequences. Lineage A predominated (96.1%), mainly represented by sublineages A1 (84.3%) and A2 (9.8%). The E6 region showed higher variability than E7: 31.4% were identical to the reference (K02718), 51.0% carried the L83V (T350G) mutation, while Q14H, D25N, and D25E were also observed. In E7, only one non-synonymous substitution was detected (N29S). No site-specific variants were detected between anal and oral samples. Overall, these findings confirm the predominance of European A1/A2 variants in Italian MSM and suggest that E6/E7 polymorphisms are not directly linked to lesion grade or anatomical localization.

Hepatitis delta virus (HDV) infection is associated with severe hepatic complications and rapid progression towards liver cirrhosis and hepatocellular carcinoma. Accurate measurement of HDV RNA is critical for monitoring therapeutic responses, especially during treatment with novel therapies such as bulevirtide (BLV). This study compared the analytical performance of two HDV RNA quantification assays, Bosphore (Anatolia) and AltoStar^® (Altona), focusing on their sensitivity, specificity, and potential implications for clinical management. Sixty-one clinical samples from twenty-four patients, including fifteen HDV-infected patients receiving BLV treatment and nine controls, were tested using each assay. Of 30 samples identified as HDV-negative by the Bosphore assay, 17 (56.7%) were HDV-positive with AltoStar^®, demonstrating the superior sensitivity (p < 0.0001) of the latter assay. Quantitative analyses revealed consistently higher viral load measurements with AltoStar^® compared to Bosphore, with a difference of 1.23 Log IU/mL and a moderate correlation (r² = 0.7385) between assays. Each assay demonstrated a high specificity, with no false positives detected among control samples. However, our findings suggest that differences in assay sensitivity could impact the evaluation of virological response, highlighting the risk of false-negative results in chronically HDV-infected patients with low-level viremia. This emphasizes the need for careful assay selection to accurately monitor treatment outcomes.

Background: Hepatitis delta virus (HDV) infection represents the most severe form of viral hepatitis and is a significant global health challenge. Bulevirtide (BLV) is a novel therapeutic treatment that has resulted in variable response rates in HBV/HDV-coinfected patients. We evaluated clinical, virological, and polymorphic factors for the purpose of predicting BLV treatment success. Methods: Thirty HBV/HDV-coinfected patients received BLV monotherapy (2 mg/day) for 24 to 48 weeks. Baseline (BL) serum samples were collected to assess clinical parameters and virological markers (HDV RNA, HBV DNA, HBsAg, HBcrAg, anti-HBc IgG) at treatment weeks 24 (TW24) and 48 (TW48). Additionally, full-genome HDV sequencing and a phylogenetic analysis were performed. Finally, analyses of the HDAg protein sequence and HDV RNA secondary structure were conducted to evaluate potential associations with treatment response. Results: A significant reduction in HDV RNA levels was observed at TW48, with a virological response (HDV RNA undetectable or ≥2 Log decline from BL) achieved by 58% of patients. Median BL levels of anti-HBc IgG were significantly different between virological responders (39.3 COI; interquartile range [IQR] 31.6–47.1) and virological non-responders (244.7 COI; IQR 127.0–299.4) (p = 0.0001). HDV genotype 1e was predominant across the cohort, and no specific HDAg polymorphisms predicted the response. However, secondary structure analysis of HDV RNA revealed that a specific pattern of internal loops in the region 63–100 nucleotides downstream of the editing site may influence treatment response by impacting editing efficacy. Conclusions: This study revealed key factors influencing BLV efficacy in HBV/HDV coinfection. Lower baseline anti-HBc IgG levels strongly correlated with a positive virological response, suggesting that the liver’s inflammatory state affects treatment success. Additionally, the analysis of HDV RNA secondary structure in patients receiving BLV treatment revealed a higher editing efficiency in virological responders, highlighting areas for further research.

Persistence is a strategy used by many viruses to evade eradication by the immune system, ensuring their permanence and transmission within the host and optimizing viral fitness. During persistence, viruses can trigger various phenomena, including target organ damage, mainly due to an inflammatory state induced by infection, as well as cell proliferation and/or immortalization. In addition to immune evasion and chronic inflammation, factors contributing to viral persistence include low-level viral replication, the accumulation of viral mutants, and, most importantly, maintenance of the viral genome and reliance on viral oncoprotein production. This review focuses on the process of genome integration, which may occur at different stages of infection (e.g., HBV), during the chronic phase of infection (e.g., HPV, EBV), or as an essential part of the viral life cycle, as seen in retroviruses (HIV, HTLV-1). It also explores the close relationship between integration, persistence, and oncogenesis. Several models have been proposed to describe the genome integration process, including non-homologous recombination, looping, and microhomology models. Integration can occur either randomly or at specific genomic sites, often leading to genome destabilization. In some cases, integration results in the loss of genomic regions or impairs the regulation of oncogene and/or oncosuppressor expression, contributing to tumor development.

Rift Valley Fever virus (RVFV) is a mosquito-borne virus with high pathogenic potential in ruminants and humans. Due to its high potential for spreading, it is considered a priority pathogen, and it is included in the Bluepoint list of the World Health Organization (WHO). Given the high pathogenic potential of the virus, it is crucial to develop a rapid heat-mediated inactivation protocol to create a safer working environment, particularly in medical facilities that lack a biosafety level 3 laboratory required for direct handling of RVFV. Our results reveal the broad tissue tropism of RVFV, showing the virus’s capacity for replication in various cell lines. In terms of the thermal stability of RVFV, our findings showed that a 70 °C heat treatment did not fully inactivate the virus within 15 min. However, when exposed to 80 °C and 95 °C, the virus was completely inactivated after 15 min and 5 min, respectively. Additionally, our results indicated that heat-treatment only slightly decreased the integrity of the RVFV genome whether there is a high or low number of viral RNA copies. Overall, the study established a straightforward protocol for heat inactivation that may be beneficial in handling clinical and research samples of RVFV.

Viral spillover represents the transmission of pathogen viruses from one species to another that can give rise to an outbreak. It is a critical concept that has gained increasing attention, particularly after the SARS-CoV-2 pandemic. However, the term is often used inaccurately to describe events that do not meet the true definition of spillover. This review aims to clarify the proper use of the term and provides a detailed analysis of the mechanisms driving zoonotic spillover, with a focus on the genetic and environmental factors that enable viruses to adapt to new hosts. Key topics include viral genetic variability in reservoir species, biological barriers to cross-species transmission, and the factors that influence viral adaptation and spread in novel hosts. The review also examines the role of evolutionary processes such as mutation and epistasis, alongside ecological conditions that facilitate the emergence of new pathogens. Ultimately, it underscores the need for more accurate predictive models and improved surveillance to better anticipate and mitigate future spillover events.