Three players were sent off and 37 fouls awarded in a match which saw Team USA reduced to nine players for all but two minutes of the second half.
The Italians took the lead on 22 minutes after sustaining a long period of American attack.
It was a goal that was made in Milan as AC midfielder Andrea Pirlo curled in a free kick for club mate Alberto Gilardino to turn into the net.
Just five minutes later, Italian defender Cristian Zaccardo registered the first clanger of the tournament when he completely mis-hit a clearance from a corner with the ball flying into his own net.
It was then that the red mist descended on the game.
On 28 minutes Italian midfielder Daniele De Rossi was shown a straight red for a sickening elbow to the face of USA striker Brian McBride.
|The Italians see off another Pope|
But the numerical advantage didn’t last until the end of the half when Bruce Arena's men lost a player of their own in defender Pablo Mastroreni for his two footed challenge on Pirlo.
Just two minutes into the second half defender Eddie Pope received his second yellow card of the match and, to the dismay of the USA coaching staff and their fans, they were down to nine.
The dreaded flag
The Americans almost had an unlikely victory when substitute DeMarcus Beasley sent the ball into the back of the net on 65 minutes, only for it to be waved away under the 'passive' off side rule, striker McBride the culprit.
The Italians used the extra man well, creating an overlap down the flanks, but it was often in vain with their strikers caught offside a staggering 11 times during the match.
Italian coach Marcello Lippi went looking for the victory which would have guaranteed his side a place in the knock out phase and he looked for the creative genius of Juventus striker Alessandro Del Piero to provide that.
The talisman came closest to the win with a cheeky flick on from an audacious chip, but American keeper Kasey Keller extended himself to make the save and keep the USA hopes alive.
Alberto Gilardino hits the right
The sides had engaged in a war of words before the match after USA striker Eddie Johnson had likened the fixture to a war and it was clear there was plenty of feeling in the match.
There was also plenty of drama and it will continue in Group E on the final day.
Last day drama
The Italians, who currently top the Group, will qualify with a win or a draw against the Czech Republic.
Should they lose they will hope to rely on their goal advantage to keep them above either Ghana or the USA.
The USA plays Ghana and need to win.
They will also be hoping tonight’s opponents Italy defeat the Czech Republic.
Should the Czech Republic win, the Americans will need to overturn the Italian’s five goal differential to qualify.