Broad range molecular detection methods identify only Borrelia spp. in erythema migrans biopsies and blood of tick-bitten patients.

In this multicenter study conducted in France, we challenged the hypothesis of the transmission of pathogens other than Borrelia spp. in 22 patients developing erythema migrans following a tick bite. Using a combination of high-throughput microfluidic PCRs and agnostic metagenomics on skin biopsies and blood samples, no microorganisms other than Borrelia spp. was found.

Optimized decision algorithm for the microbiological diagnosis of osteoarticular infections in adults using synovial fluid samples: a prospective study in two French hospitals including 423 samples of synovial fluid.

No consensus exists about the techniques to use for microbiological diagnosis of bone and joint infections (BJIs). The objective herein was to define an algorithm to optimize BJI diagnosis in adults using various bacteriological methods on synovial fluid samples. This prospective multi-center study included 423 synovial fluids collected from adult patients with suspected BJIs. Culture (using five solid media, an enrichment broth, and blood culture bottles), universal 16S rRNA PCR followed by Sanger sequencing, and seven specific bacterial PCRs were systematically performed. Combinations of methods were compared to arrive at the optimized algorithm. Among 423 synovial fluids, 242 infections were diagnosed (57.2 %): 213 mono- and 29 poly-microbial for a total of 284 bacteria (staphylococci at 54.6 %, streptococci-enterococci at 16.5 %, Gram-negative bacilli at 15.5 %, anaerobic species at 8.8 %). Comparing culture techniques, blood culture bottles had the highest sensitivity (67.6 % for pediatric and 63.9 % for anaerobic bottles) but are not sufficient alone and require being combined with solid media. The 16S rDNA PCR detected only 52.3 % of the bacteria, whereas specific PCRs had a higher sensitivity (Staphylococcus spp. at 66.2 %, S. aureus at 85.2 %, Streptococcus spp. at 91.2 %). Based on these results, an algorithm was proposed associating three solid media; inoculation into blood culture bottles; and 16S, Staphylococcus spp., and Streptococcus spp. PCRs, which would have detected 90.5 % of bacteria in the present cohort versus 79.2 % using all culture techniques on synovial fluid. This prospective study shows that a combination of culture and molecular methods on synovial fluids allows the optimization of bacterial detection.

Staphylococcus lugdunensis prosthetic joint infection: A multicentric cohort study.

OBJECTIVES: To describe Staphylococcus lugdunensis prosthetic joint infection (PJI) management and outcome. METHODS: Adults with proven S. lugdunensis PJI were included in a multicentric retrospective cohort. Determinants for failure were assessed by logistic regression and treatment failure-free survival curve analysis (Kaplan-Meier). RESULTS: One hundred and eleven patients were included (median age 72.4 [IQR, 62.7-79.4] years), with a knee (n = 71, 64.0%) or hip (n = 39, 35.1%) PJI considered as chronic in 77 (69.4%) cases. Surgical management consisted in debridement, antibiotic with implant retention (DAIR; n = 60, 54.1%), two-stage (n = 28, 25.2%) or one-stage (n = 15, 13.5%) exchange. Total duration of antimicrobial therapy was 13.1 (IQR, 11.8-16.9) weeks. After a median follow-up of 99.9 (IQR, 53.9-178.1) weeks, 22 (19.8%) S. lugdunensis-related treatment failures were observed. Independent determinants for outcome were diabetes (OR, 3.741; p = 0.036), sinus tract (OR, 3.846; p = 0.032), DAIR (OR, 3.749; p = 0.039) and rifampin-based regimen (OR, 0.319; p = 0.043). Twenty-four (40.0%) of the 60 DAIR-treated patients experienced treatment failure, with hip location (OR, 3.273; p = 0.048), delay from prosthesis implantation (OR, 1.012 per month; p = 0.019), pre-surgical CRP level >115 mg/L (OR, 4.800; p = 0.039) and mobile component exchange (OR, 0.302; p = 0.069) constituting additional determinants of outcome. CONCLUSIONS: Staphylococcus lugdunensis PJI are difficult-to-treat infections, with pivotal roles of an optimal surgical management.

Masquelet's induced membrane technique associated with Reamer Irrigation Aspiration grafting and intramedullary Nailing (MaRIAN) for chronic diaphyseal osteomyelitis of the lower limb.

INTRODUCTION: Masquelet's induced membrane technique offers a definitive contribution to the treatment of diaphyseal osteomyelitis. To overcome its drawbacks while maintaining its principles, technical modifications have been proposed: antibiotic cement, femoral intramedullary autograft harvested by RIA (Reamer Irrigation Aspiration) and interlocking nails. MATERIAL AND METHOD: This retrospective study gathered patients with chronic osteomyelitis of the femur or tibia. The first surgical stage consisted of bone resection in the healthy zone and use of a gentamicin cement spacer to fill the bone defect. The second stage consisted of the placement of a statically locked intramedullary nail associated with a bone autograft using the RIA technique. RESULTS: Among this group of 12 men with diaphyseal osteomyelitis; 9 tibial and 2 femoral, and 1 knee nonunion, the mean bone defect was 7.3cm (±6.7). The mean time between the 2 stages was 2.7months (±3) with a mean antibiotic period of 3.25weeks (±3). There was a femoral diaphyseal fracture at the donor site, and a wrong trajectory intraoperatively during the RIA. Two patients with tibial nonunion presented with nail rupture without septic recurrence. A septic recurrence was healed by removal of the nail. At a minimum follow-up of 18months, with an average of 5years, consolidation was complete without infectious recurrence. Despite the statistical weakness related to the size of the cohort, the resumption of early weight bearing (OR=-7.68 95% CI [-13.33 to -2.08] (p=0.01)) and nail dynamization seemed to have an impact on the formation of complete consolidation (OR=-0.86 95% CI [-1.39 to -0.33] (p=0.007)). DISCUSSION AND CONCLUSION: This short series, compared to the literature, demonstrated that the proposed technical modifications improved the overall management of this rare and challenging condition while maintaining the reliability of the original technique. Dynamization was also seen to be of particular interest. LEVEL OF EVIDENCE: IV, retrospective study.

Management of Long COVID-The CoviMouv' Pilot Study: Importance of Adapted Physical Activity for Prolonged Symptoms Following SARS-CoV2 Infection.

Context: After a COVID-19 infection, some patients have persistent symptoms, the most common is fatigue. To prevent it from becoming chronic (post-COVID-19 syndrome), early management before 3 months could be useful. Exercise and education are recommended. Objective: To assess fatigue in patients with prolonged symptoms after COVID-19 infection and who received a mixed program of remote adapted physical activity and therapeutic education. The secondary objective was to evaluate the efficacy and safety of this training method thanks to aerobic and anaerobic parameters. Methods: "CoviMouv': From Coaching in Visual to Mouv in real" is a nonrandomized controlled pilot study. Patients in telerehabilitation followed 12 remote exercise sessions and 3 therapeutic education workshops. Patients on traditional rehabilitation followed their program with a community-based physiotherapist. Results: Fatigue was reduced after the one-month intervention in both groups (p = 0.010). The majority of aerobic parameters were significantly improved, e.g., maximal oxygen uptake (p = 0.005), walking distance (p = 0.019) or hyperventilation values (p = 0.035). The anaerobic parameter was not improved (p = 0.400). No adverse event was declared. Discussion: Telerehabilitation is a good alternative when a face-to-face program is not possible. This care at an early stage of the disease could help prevent the chronicity of post-COVID-19 symptoms and the installation of vicious circles of physical deconditioning. A larger study would be necessary.

Exploring convolutional neural networks with transfer learning for diagnosing Lyme disease from skin lesion images.

BACKGROUND AND OBJECTIVE: Lyme disease which is one of the most common infectious vector-borne diseases manifests itself in most cases with erythema migrans (EM) skin lesions. Recent studies show that convolutional neural networks (CNNs) perform well to identify skin lesions from images. Lightweight CNN based pre-scanner applications for resource-constrained mobile devices can help users with early diagnosis of Lyme disease and prevent the transition to a severe late form thanks to appropriate antibiotic therapy. Also, resource-intensive CNN based robust computer applications can assist non-expert practitioners with an accurate diagnosis. The main objective of this study is to extensively analyze the effectiveness of CNNs for diagnosing Lyme disease from images and to find out the best CNN architectures considering resource constraints. METHODS: First, we created an EM dataset with the help of expert dermatologists from Clermont-Ferrand University Hospital Center of France. Second, we benchmarked this dataset for twenty-three CNN architectures customized from VGG, ResNet, DenseNet, MobileNet, Xception, NASNet, and EfficientNet architectures in terms of predictive performance, computational complexity, and statistical significance. Third, to improve the performance of the CNNs, we used custom transfer learning from ImageNet pre-trained models as well as pre-trained the CNNs with the skin lesion dataset HAM10000. Fourth, for model explainability, we utilized Gradient-weighted Class Activation Mapping to visualize the regions of input that are significant to the CNNs for making predictions. Fifth, we provided guidelines for model selection based on predictive performance and computational complexity. RESULTS: Customized ResNet50 architecture gave the best classification accuracy of 84.42% ±1.36, AUC of 0.9189±0.0115, precision of 83.1%±2.49, sensitivity of 87.93%±1.47, and specificity of 80.65%±3.59. A lightweight model customized from EfficientNetB0 also performed well with an accuracy of 83.13%±1.2, AUC of 0.9094±0.0129, precision of 82.83%±1.75, sensitivity of 85.21% ±3.91, and specificity of 80.89%±2.95. All the trained models are publicly available at https://dappem.limos.fr/download.html, which can be used by others for transfer learning and building pre-scanners for Lyme disease. CONCLUSION: Our study confirmed the effectiveness of even some lightweight CNNs for building Lyme disease pre-scanner mobile applications to assist people with an initial self-assessment and referring them to expert dermatologist for further diagnosis.

Methodological Quality Assessment with the AGREE II Scale and a Comparison of European and American Guidelines for the Treatment of Lyme Borreliosis: A Systematic Review.

BACKGROUND: Most European and American countries recently updated their guidelines on Lyme borreliosis (LB). The aim of this study was to provide a comparative overview of existing guidelines on the treatment of LB in Europe and America and to assess the methodological quality of their elaboration. METHODS: A systematic search was carried out in MEDLINE, Google Scholar, and the national databases of scientific societies from 2014 to 2020. Quality was assessed by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. RESULTS: Twelve guidelines were included. The scores for the AGREE II domains (median ± IQR) were: overall assessment 100 ± 22, scope and purpose 85 ± 46, stakeholder involvement 88 ± 48, rigour of development 67 ± 35, clarity of presentation 81 ± 36, applicability 73 ± 52 and editorial independence 79% ± 54%. Cohen's weighted kappa showed a high agreement (K = 0.90, 95%CI 0.84-0.96). Guidelines were quite homogeneous regarding the recommended molecules (mostly doxycycline in the first intention and ceftriaxone in the second intention), their duration (10 to 28 days), and their dosage. The differences were due to the lack of well-conducted comparative trials. The International Lyme and Associated Diseases Society (ILADS) guidelines were the only ones to suggest longer antibiotics based on an expert consensus. CONCLUSION: European and American guidelines for the treatment of LB were quite homogeneous but based on moderate- to low-evidence studies. Well-conducted comparative trials are needed to assess the best molecules, the optimal duration and the most effective doses.

Salmonella infection after anterior cruciate ligament reconstruction: A case report.

BACKGROUND: Infections after anterior cruciate ligament reconstruction (ACLR) are rare. No cases of Salmonella infection have been described to our knowledge. CASE SUMMARY: We describe a rare case of Salmonella infection in a 23-year-old patient following an ACLR. The patient presented with subacute septic arthritis, 26 d after a hamstring autograft ACLR. The pathogen, Salmonella enterica typhimurium was isolated by bacteriological sampling of the first arthroscopic lavage. Two arthroscopic lavages were required, with intravenous antibiotic therapy for two weeks with cefotaxime and ciprofloxacin, followed by oral antibiotics with amoxicillin and ciprofloxacin for a total duration of three months. This approach treated the infection but two years after the septic arthritis, faced with ongoing knee instability due to graft damage, a revision ACLR with a bone-tendon-bone graft was performed. At the last follow-up, full range of knee motion had been achieved and sports activities resumed. CONCLUSION: Infection after ACLR is rare and requires an early diagnosis and management in order to treat the infection and prevent arthritis-related joint cartilage destruction and damage to the graft.

[Borreliosis and relapsing fever]. / Borrélioses et fièvres récurrentes.

BORRELIOSIS AND RELAPSING feverrelapsing fevers borreliosis (RFB) are caused by bacteria of the genus Borrelia, within the spirochete's family, transmitted to Humans by arthropods (lice Pediculus humanus, soft ticks of the genus Ornithodoros, or hard ticks for one of them). The RFB transmitted by body lice is cosmopolitan and occurs during epidemics in the context of major crises (promiscuity, precarious hygiene conditions, food crises, etc.). RFB transmitted by ticks are distributed by region, according to the Borrelia species and the geographical repartition of the tick involved (sporadic transmission). The incubation period varies from 3 to 20 days. The first febrile phase lasts 3 days (1-14 days), followed by a phase of apyrexia with persistence of other clinical signs (skin rash, petechiae, headaches, agitation, polyarthromyalgia, abdominal pain, nausea/vomiting, etc.). The recurrence of fever occurs every 7 days on average. Bacteremia in the blood is abundant during fever allowing direct diagnosis by microscopy, Borrelia PCR or culture on a specific medium when available. The first-line treatment is doxycycline, except in case of neurological involvement (ceftriaxone). The mortality Rate varies from 2 to 5 % depending on the Borrelia Species involved. The outcome is usually good after treatment.

Borrélioses et fièvres récurrentes Les borrélioses récurrentes (br) ou fièvres récurrentes sont dues à des bactéries du genre borrelia, de la famille des spirochètes, transmises à l'homme par des arthro¬podes vecteurs (poux de corps, tiques molles, et tiques dures pour l'une d'entre elles). La br à poux est cosmo¬polite et transmise lors d'épidémies survenant dans le contexte de crises majeures (promiscuité, conditions d'hygiène précaires, crise alimentaire, etc.). Les br à tiques se répartissent par région, selon la borrelia en cause et la distribution géographique de leur tique vec¬trice. Le temps d'incubation varie de 3 à 20jours. La première phase fébrile dure 3jours (1-14jours), suivie d'une phase d'apyrexie avec persistance des autres signes cliniques (rash cutané, pétéchies, céphalées in¬tenses, agitation, polyarthromyalgies, douleurs abdomi¬nales, nausées/vomissements, etc.). La récurrence de la fièvre décrit une périodicité de 7jours en moyenne. La bactériémie est abondante lors des pics fébriles, permet¬tant de poser un diagnostic par examen direct en mi¬croscopie, pcr borrelia ou culture sur milieu spécial, quand celle-ci est possible. Le traitement repose sur la doxycycline, sauf pour les formes neurologiques (ceftriaxone). Le taux de mortalité varie de 2 à 5 % selon la borrelia incriminée. L'évolution est le plus souvent favorable après traitement.

Methods and probability of success after early revision of prosthetic joint infections with debridement, antibiotics and implant retention.

Prosthetic joint infection (PJI) is a rare-and dreaded-complication of arthroplasty requiring multidisciplinary care. Given the dual goal of treating the infection and maintaining satisfactory function, it is preferable to determine how and when the implanted components can be retained. Bacteria and fungi organize themselves into biofilms that shield them from antibiotics and the immune system. This biofilm is in place after 15 days of active infection. Some antibiotics have a better activity on biofilms. The following factors have a negative impact on the probability of a successful debridement, antibiotics and implant retention (DAIR) intervention: fracture or revision, use of cement, bacteremia, kidney and/or liver failure, immunosuppression and elevated CRP. Hematogenous infections have a worse prognosis than early postoperative infections. Using a decision algorithm increases the chances of DAIR being successful. The KLIC score applies to early postoperative infections (<4 weeks postoperative and<3 weeks from the first signs) while the CRIME-80 score applies to hematogenous infections (<3 weeks from the first signs). Arthroscopic treatments have no role here, whereas DAIR through an arthrotomy is well standardized. Wide spectrum antibiotic therapy, secondarily adapted to the causative microorganism, is indicated for a total of 3 months. The results against the infection are mixed, although following a decision algorithm resolves the infection in about 75% of cases. The functional outcomes and quality of life are close to those of patients who have undergone primary joint replacement. It is not recommended to carry out a second DAIR if the first one fails. It is logical to apply the principles set out for the hip and knee to other joint replacements, and to use the same algorithm. For the upper limb, and especially for reverse shoulder arthroplasty, one must be careful about Cutibacterium acnes infections as they are hard to diagnose. Surgeons should not hesitate to contact a referral center for any PJI, although it is preferable that early infections be treated at the facility that performed the implantation.

Devastating Gynecological Infections in Women with STAT3 Deficiency.

We provide the first description of a series of 9 severe gynecological infections (mastitis and pelvic cellulitis) occurring in the French national cohort of women with STAT3 deficiency. Each episode had unique features in terms of clinical presentation, microbial documentation, location, treatment duration, and related persistent esthetic damage.

Anti-N-methyl-D-aspartate receptor encephalitis after Herpes simplex virus-associated encephalitis: an emerging disease with diagnosis and therapeutic challenges.

INTRODUCTION: Morbidity and mortality of Herpes simplex virus encephalitis (HSE) remain high. Relapses of neurological signs may occur after initial clinical improvement under acyclovir treatment. METHODS: We report here a case of post-HSE anti-N-methyl-d-aspartate receptor-mediated encephalitis in an adult and perform a systematic search on PubMed to identify other cases in adults. RESULTS: We identified 11 previously published cases, to discuss diagnostic and therapeutic management. Symptoms in adults are often inappropriate behaviors, confusion and agitation. Diagnosis of anti-NMDA-R encephalitis after HSE is often delayed. Treatment consists in steroids, plasma exchange, and rituximab. Prognosis is often favorable. CONCLUSION: Anti-NMDA-R antibodies should be searched in cerebrospinal fluid of patients with unexpected evolution of HSE. This emerging entity reopens the hot debate about steroids in HSE.

Identifying Hemodialysis Patients With the Highest Risk of Staphylococcus aureus Endogenous Infection Through a Simple Nasal Sampling Algorithm.

In contrast to Staphylococcus aureus intermittent nasal carriers, persistent ones have the highest risk of infection. This study reports the usefulness of a simple nasal sampling algorithm to identify the S. aureus nasal carriage state of hemodialysis patients (HPs) and their subsequent risk of infection.From a cohort of 85 HPs, 76 were screened for S. aureus nasal carriage once a week during a 10-week period. The S. aureus nasal load was quantified by using either culture on chromogenic medium or fully automated real-time polymerase chain reaction assay. Molecular typing was used to compare strains from carriage and infection.The algorithm based on quantitative cultures was able to determine the status of S. aureus nasal carriage with a sensitivity of 95.8%, a specificity of 94.2%, a positive predictive value of 88.5%, and a negative predictive value of 98.0%. Of note, the determination of the S. aureus carriage state was obtained on the first nasal sample for all the 76 HPs, but 1 (98.7%). The algorithm based on quantitative polymerase chain reaction assay directly from the specimen yielded similar performances. During the 1-year follow-up after the last sampling episode, HPs classified as persistent nasal carriers with the algorithm were found to have a higher risk of S. aureus infection than those classified as nonpersistent carriers (P < 0.05), especially for infections of endogenous origin (P < 0.001).This simple algorithm is reliable for determining the S. aureus nasal carriage status in clinical practice and could contribute to characterize at an early stage of take-up patients with the highest risk of S. aureus infection.

Mycoplasma hominis, a Rare but True Cause of Infective Endocarditis.

Mycoplasma spp. are rarely recognized agents of infective endocarditis. We report a case of Mycoplasma hominis prosthetic valve endocarditis diagnosed by 16S ribosomal DNA (rDNA) PCR and culture of valves in a 74-year-old man. We reviewed the literature and found only 8 other cases reported.

Guillain-Barré syndrome associated with Mycobacterium bovis lymphadenitis.

Guillain-Barré syndrome (GBS) is an autoimmune disease that can be triggered by different infectious agents. Here we report the case of a 26-year-old Algerian woman who developed GBS associated with a Mycobacterium bovis cervical lymphadenitis. Following intravenous immunoglobulin therapy, the patient's neurologic state returned to normal after 3 months. The lymphadenitis responded more slowly to the antituberculous treatment and an excision of necrotic cervical lymph nodes had to be performed four times. Antibiotics were administered for 16 months: ethambutol was stopped after 2 months, and rifampicin and isoniazid pursued for 14 months. An extensive etiological investigation showed that, in this case, the only likely infectious trigger GBS was the concomitant M. bovis infection. To our knowledge, this is the first report of GBS triggered by M. bovis. We performed a literature review revealing that the association between tuberculosis and Guillain-Barré syndrome is very rare (only seven cases previously reported) but is not coincidental. Physicians should be aware that tuberculosis can be a cause of GBS.

Are the risk factors associated with Staphylococcus aureus nasal carriage in patients the same than in healthy volunteers? Data from a cohort of patients scheduled for orthopedic material implantation.

The risk factors for Staphylococcus aureus nasal carriage have been mainly defined in healthy volunteers. Using data from a large multicenter prospective clinical cohort of orthopedic surgical patients we showed that obesity (BMI > 30) and younger age were independent risk factors for persistent carriage. In the absence of recommendations for S aureus decolonization in orthopedic surgery, this study suggests that at least obese patients should be targeted to prevent surgical site infections.

Acute acalculous cholecystitis, a rare complication of Epstein-Barr virus primary infection: report of two cases and review.

We described two cases of acalculous cholecystitis (AAC), due to EBV primary infection in two young Caucasian women and we reviewed other reported cases. In contrast with AAC of other etiologies, antibiotics and surgery are not useful in the management of AAC secondary to EBV.