Rickettsia sibirica mongolitimonae Infection, France, 2010-2014.

To further characterize human infections caused by Rickettsia sibirica mongolitimonae, we tested skin biopsy and swab samples and analyzed clinical, epidemiologic, and diagnostic characteristics of patients with a rickettsiosis. The most common (38%) indigenous species was R. sibirica mongolitimonae. Significantly more cases of R. sibirica mongolitimonae infection occurred during spring and summer.

Neutralization-based seroprevalence of Toscana virus and sandfly fever Sicilian virus in dogs and cats from Portugal.

Sandfly-borne phleboviruses are endemic in the Mediterranean basin. However, levels of exposure of human and animal populations are inadequately researched. Toscana virus (TOSV) is present in Portugal where it causes human infection and disease; in contrast there are few data for sandfly fever Sicilian virus (SFSV) which has neither been isolated nor detected by molecular tests and for which there are only limited serological data. The sera collected from 1160 dogs and 189 cats in southern Portugal were tested for the presence of neutralizing antibodies against TOSV and SFSV, two viruses recognized as distinct serocomplexes in the Mediterranean region. Our data showed (i) seropositivity to TOSV and SFSV in dogs at a rate of 6.8 and 50.8 %, respectively, and (ii) that 3.7 % of cats were seropositive for TOSV. TOSV findings are in line with previous results obtained with less stringent serological assays. Our results for SFSV in dogs clearly indicate that the virus is circulating widely and that humans may be exposed to infection via the dogs. Although the presence of SFSV was suggested by haemagglutination inhibition in 4/1690 human sera in 1974, this is the first time, as far as we know, that SFSV has been shown to circulate so widely in dogs in Portugal. Future studies should be directed at isolating strains of SFSV in Portugal from dogs, humans and sandflies collected in high prevalence regions. As dogs appear to be good sentinels for SFSV, their role as a possible reservoir in the natural cycle should also be considered.

Relationship between HPV 16, 18, 31, 33, 45 DNA detection and quantitation and E6/E7 mRNA detection among a series of cervical specimens with various degrees of histological lesions.

Better understanding of the correlation between high-risk HPV DNA testing, viral load quantitation, and E6/E7 mRNA detection is required. The aim of this study was to assess the relationship between these markers and the severity of cervical lesions. One-hundred and fifty one directed cervical specimens were analysed (normal, cervical intraepithelial neoplasia, and cancer). HPV types 16, 18, 31, 33, and 45 DNA detection and quantititation and E6/E7 mRNA detection were performed. DNA was detected in 87 (57.6%) samples and increased from 0% (normal) to 93.9% (cancer). E6/E7 mRNA was detected in 65 (43%) samples and increased with the severity of the lesions from 0% (normal) to 78.8% (26/33) (cancers) (P < 0.001). HPV DNA and E6/E7 mRNA detection were compared in the 141 samples harbouring HPV16, 18, 31, 33, or 45 infection: 45.4% (64/141) of specimens were DNA-/mRNA-, 46% (65/141) were DNA + /mRNA+ and 8.5% (12/141) were DNA + /mRNA-. The proportion of DNA + /mRNA+ specimens increased with the severity of the lesions (P < 0.001). All normal cervix specimens were DNA-/mRNA-. Among grade 2 cervical intraepithelial neoplasia, prevalence of DNA was higher than that of mRNA: 41.6% (5/12) versus 25% (3/12), whereas it was 79.3% (46/58) versus 62% (36/58) among grade 3 cervical intraepithelial neoplasia. Full concordance was observed in cancers as all the 26 DNA+ specimens were mRNA +. Median overall HPV load was higher in DNA + /mRNA+ than in DNA + /mRNA- specimens (1.41 × 10(6) vs. 9.1 × 10(2) copies per million cells, P < 0.001). Both E6/E7 mRNA detection and concordant DNA + /mRNA+ detection increases with the severity of the lesions and with the HPV DNA load.

Emergence of clusters of CRF02_AG and B human immunodeficiency viral strains among men having sex with men exhibiting HIV primary infection in southeastern France.

The number of new HIV diagnoses is increasing in the western world and transmission clusters have been recently identified among men having sex with men despite Highly Active Antiretroviral Therapy efficacy. The objective of this study was to assess temporal trends, epidemiological, clinical and virological characteristics of primary HIV infections. A retrospective analysis of 79 patients presenting primary HIV infections from 2005 to 2012 was performed in Marseille University Hospitals, southeastern France. Clinical, epidemiological and immunovirological data including phylogeny based on the polymerase gene were collected. 65 males and 14 females were enrolled. The main transmission route was homosexual contact (60.8%). Patients were mostly infected with subtype B (73.4%) and CRF02_AG (21.5%) HIV-1 strains. An increase in the annual number of HIV seroconversions among new HIV diagnoses from 5% in 2005 to 11.2% in 2012 (P = 0.06) and of the proportion of CRF02_AG HIV strains among primary HIV infections in 2011-2012 as compared to 2005-2010 (P = 0.055) was observed. Phylogenetic analysis revealed four transmission clusters including three transmission clusters among men having sex with men: two large clusters of nine CRF02_AG, six B HIV strains; and one small cluster of three B HIV strains. Clusters involved more frequently men (P = 0.01) belonging to caucasian ethicity (P = 0.05), with a higher HIV RNA load at inclusion (P = 0.03). These data highlight the importance of improving epidemiological surveillance and of implementing suitable prevention strategies to control the spread of HIV transmission among men having sex with men.

Bacterial lymphadenitis at a major referral hospital in France from 2008 to 2012.

Lymph node enlargement is a common medical problem, and in a large number of patients, the causes of lymphadenopathy remain undiagnosed. We report a thorough microbiological analysis of 1,688 lymph node biopsy specimens collected in our bartonellosis reference center. We studied lymph node biopsy samples from patients with suspected regional infectious lymph node enlargement from January 2008 to December 2012. To evaluate a useful strategy for the diagnosis of infectious lymphadenitis, specimens were cultured and subjected to molecular assays. Histologic analysis was done when possible. A total of 642 (38%) biopsy specimens were infected with a bacterial agent, and quantitative PCR (qPCR) was significantly better than 16S rRNA gene PCR (rrs) for the detection of Bartonella henselae (P = 0.05), Mycobacterium tuberculosis (P = 0.05), and Mycobacterium avium (P = 0.007). Molecular assays were significantly better than bacterial cultures for the diagnosis of Francisella tularensis (P = 0.017) but were less effective for detecting M. tuberculosis (P = 0.004) and M. avium (P = 0.001). Histologic analysis was done for 412 lymph nodes, and 20% of these were compatible with an infectious lymphadenitis, whereas a neoplasm was found in 29% of these lymph nodes. M. tuberculosis was detected significantly more in female than in male patients (P = 0.01), and patients with cat scratch disease (CSD) were younger than patients with M. tuberculosis, Tropheryma whipplei, and F. tularensis. Negative rrs PCR does not exclude the diagnosis of infectious lymphadenitis. Histologic analysis of lymph node biopsy specimens is critical, as a diagnosis of infectious lymphadenitis does not preclude other concurrent diseases.

Common epidemiology of Rickettsia felis infection and malaria, Africa.

This study aimed to compare the epidemiology of Rickettsia felis infection and malaria in France, North Africa, and sub-Saharan Africa and to identify a common vector. Blood specimens from 3,122 febrile patients and from 500 nonfebrile persons were analyzed for R. felis and Plasmodium spp. We observed a significant linear trend (p<0.0001) of increasing risk for R. felis infection. The risks were lowest in France, Tunisia, and Algeria (1%), and highest in rural Senegal (15%). Co-infections with R. felis and Plasmodium spp. and occurrences of R. felis relapses or reinfections were identified. This study demonstrates a correlation between malaria and R. felis infection regarding geographic distribution, seasonality, asymptomatic infections, and a potential vector. R. felis infection should be suspected in these geographical areas where malaria is endemic. Doxycycline chemoprophylaxis against malaria in travelers to sub-Saharan Africa also protects against rickettsioses; thus, empirical treatment strategies for febrile illness for travelers and residents in sub-Saharan Africa may require reevaluation.

Real-time PCR quantification of Methanobrevibacter oralis in periodontitis.

A real-time PCR assay developed to quantify Methanobrevibacter oralis indicated that its inoculum significantly correlated with periodontitis severity (P = 0.003), despite a nonsignificant difference in prevalence between controls (3/10) and patients (12/22) (P = 0.2, Fisher test). The M. oralis load can be used as a biomarker for periodontitis.

Diagnostic yield of FDG positron-emission tomography/computed tomography in patients with CEID infection: a pilot study.

AIMS: Whole body imaging with (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) has proven useful in various infectious diseases. The purpose of this pilot study was to assess the diagnostic yield of FDG PET/CT in patients with cardiac implantable electronic device (CIED) infection. METHODS AND RESULTS: A total of 21 patients with CIED infection were prospectively included. Diagnosis of CIED infection was made in accordance with current criteria. It was classified in three categories, i.e. superficial skin infection, pocket site infection, or cardiac device-related infective endocarditis (CDRIE). All patients underwent FDG PET/CT. Scans were interpreted blindly, i.e. without prior knowledge of diagnosis, by experienced nuclear medicine physicians. The accuracy of FDG PET/CT was assessed for each diagnostic category. Findings demonstrated superficial skin infection in 1 patient, pocket site infection in 15, and CDRIE in 13 (definite: 7; possible: 6). In patients with pocket site infection, the sensitivity and specificity of FDG PET/CT were 86.7% [59.5-98.3, 95% confidence interval (CI)] and 100% [42.1-100, 95% CI]. The only patient with superficial skin infection was accurately identified by FDG PET/CT. The sensitivity and specificity of FDG PET/CT in patients with CDRIE were 30.8% [9.1-61.4, 95% CI] and 62.5% [24.5-91.5, 95% CI]. Most false-negative results occurred in patients who had undergone previous antimicrobial treatment. CONCLUSION: This study indicates that FDG PET/CT is highly accurate for the diagnosis of skin and pocket CIED infection but low for infective endocarditis. This suggests that the reliability of FDG PET/CT findings in management decision making varies according to the type of CIED infection.

Metagenomic analysis of brain abscesses identifies specific bacterial associations.

BACKGROUND: The bacterial flora involved in brain abscess is often complex. In a previous study, using a metagenomic approach based on 16S ribosomal DNA (rDNA) amplification, we demonstrated that the diversity of the microbial flora involved in these infections was underestimated. METHODS: We performed a 16S rDNA-based metagenomic analysis of cerebral abscesses from patients diagnosed from 2006 through 2010. All bacteria present in brain abscess specimens were identified, in view of the clinical and epidemiological characteristics of the patients. RESULTS: Fifty-one patients were included in our study. By detecting polymicrobial infections in 19 patients, our strategy was significantly more discriminatory and enabled the identification of a greater number of bacterial taxa than did culture and conventional 16S rDNA polymerase chain reaction (PCR) and sequencing, respectively (P < 10(-2)). Data mining discriminated 2 distinct bacterial populations in brain abscess from dental and sinusal origin. In addition, of the 80 detected bacterial species, we identified 44 bacteria that had never been found in brain abscess specimens, including 22 uncultured bacteria. These uncultured agents mostly originated from the buccal or sinusal floras (P < 10(-2)) and were found in polymicrobial specimens (P < 10(-2)). CONCLUSIONS: Cloning and sequencing of PCR-amplified 16S rDNA is a highly valuable method to identify bacterial agents of brain abscesses.

Q fever in France, 1985-2009.

To assess Q fever in France, we analyzed data for 1985-2009 from the French National Reference Center. A total of 179,794 serum samples were analyzed; 3,723 patients (one third female patients) had acute Q fever. Yearly distribution of acute Q fever showed a continuous increase. Periodic variations were observed in monthly distribution during January 2000-December 2009; cases peaked during April-September. Q fever was diagnosed more often in patients in southeastern France, where our laboratory is situated, than in other areas. Reevaluation of the current positive predictive value of serologic analysis for endocarditis was performed. We propose a change in the phase I (virulent bacteria) immunoglobulin G cutoff titer to ≥1,600. Annual incidences of acute Q fever and endocarditis were 2.5/100,000 persons and 0.1/100,000 persons, respectively. Cases and outbreaks of Q fever have increased in France.

Altitude-dependent Bartonella quintana genotype C in head lice, Ethiopia.

To determine the presence of Bartonella quintana in head and body lice from persons in different locations in Ethiopia, we used molecular methods. B. quintana was found in 19 (7%) genotype C head lice and in 76 (18%) genotype A body lice. B. quintana in head lice was positively linked to altitude (p = 0.014).

Seasonality of cat-scratch disease, France, 1999-2009.

Cat-scratch disease is seasonal in the United States and Japan; but no data are available from Europe. To assess the seasonality of the disease in France, we analyzed lymph node biopsy specimens collected during 1999-2009. Most (87.5%) cases occurred during September-April and peaked in December.

Analysis of risk factors for malignant Mediterranean spotted fever indicates that fluoroquinolone treatment has a deleterious effect.

OBJECTIVES: To identify risk factors for malignant Mediterranean spotted fever (MSF) caused by Rickettsia conorii conorii. PATIENTS AND METHODS: Epidemiological, clinical and biological characteristics as well as risk factors (including treatment regimens) for severe MSF cases were analysed retrospectively. A patient with two or more organ dysfunctions or patient death was defined as a severe case. RESULTS: During the study period (January 1999 to December 2009), 161 MSF cases were referred to our centre for rickettsioses. Twenty-six cases (16.1%) were considered severe, which is 3-fold higher than in our previous studies. The clinical and laboratory findings were comparable to those reported elsewhere except that the type of antibiotic treatment was associated with disease severity. Doxycycline administration prior to deterioration of disease (in 31 patients) protected patients from development of severe MSF [relative risk (RR) 0.248, 95% confidence interval (CI) 0.08-0.76] and induced earlier defervescence compared with the other treatment regimens (3.02 ± 2.2 days versus 7.1 ± 6.57 days, P = 0.021). In contrast, fluoroquinolone treatment (in 21 patients) was significantly and independently associated with MSF severity (RR 2.53, 95% CI 1.40-4.55) and was associated with a significantly longer hospital stay. CONCLUSIONS: In this retrospective study fluoroquinolone treatment was associated with increased MSF disease severity. Fluoroquinolones have been previously associated with treatment failure in typhus and scrub typhus cases. Thus, we do not recommend the use of fluoroquinolones to treat rickettsial diseases.

Hepatitis E virus infection in patients infected with the human immunodeficiency virus.

Hepatitis E virus (HEV) is a newly-identified causative agent of acute and chronic hepatitis in severely immunocompromized patients. The present study sought to assess the prevalences of past, recent, on-going, and chronic HEV infections in patients infected with human immunodeficiency virus (HIV) in Marseille, South-eastern France, and to determine if they were correlated with the patients' immunological status or with cirrhosis. Anti-HEV IgG and IgM and HEV RNA testing were concurrently performed on the plasma from 184 patients infected with HIV, including 81 with a CD4+ T-lymphocyte count (CD4 count) <50 cells/mm(3) and 32 with a cirrhosis. Prevalence of anti-HEV IgG and IgM was 4.4% (8/184) and 1.6% (3/184), respectively. Past, recent, and on-going infections were observed in 3.3% (6/184), 1.6% (3/184), and 0.5% (1/184) of the patients, respectively. Anti-HEV antibodies prevalence did not differ significantly according to CD4 count, cirrhosis, sex, age, mode of HIV transmission, and infection with hepatitis B or C virus. Anti-HEV IgG seroreversion was observed in two patients. The patient whose plasma tested positive for HEV RNA had a CD4 count <50 cells/mm(3) ; HEV genotype was 3f. In this patient, longitudinal testing showed HEV RNA positivity during a 10-month period, indicating chronic HEV infection; in contrast, anti-HEV IgG never tested positive. Further studies are needed to evaluate the performance of commercial HEV serological assays in patients infected with HIV and to assess the actual incidence, prevalence, and outcome of HEV infection in this special group of patients. HEV RNA testing is necessary for such purposes.

Tropheryma whipplei bacteremia during fever in rural West Africa.

BACKGROUND: Tropheryma whipplei not only causes Whipple disease but also is an emerging pathogen associated with gastroenteritis and pneumonia that is commonly detected in stool samples in rural West Africa. We investigated the role of T. whipplei in febrile patients from rural Senegal who had a negative test result for malaria. METHODS: From November 2008 through July 2009, we conducted a prospective study in 2 Senegalese villages; 204 blood specimens from febrile patients were collected. DNA extraction of whole-blood samples collected by finger pricks with a lancet stick was performed in Senegal; elution and quantitative polymerase chain reaction assays for T. whipplei were performed in France. In April 2009, we conducted a screening to look for the presence of T. whipplei in the saliva and stools of the overall population. Blood from French patients with chronic T. whipplei in stool samples was also analyzed. RESULTS: The presence of T. whipplei DNA was detected in blood from 13 (6.4%) of 204 tested patients, mostly in children and in December and January. None of the French carriers tested positive. The patients with T. whipplei bacteremia presented with fever (13 patients), cough (10), thirst (8), fatigue (7), rhinorrhea (6), and sleep disorders (5). Cough and sleep disorders were significantly more frequent in febrile carriers than in the 191 febrile episodes without T. whipplei bacteremia (P = .002 and .005, respectively). No correlation was observed between the presence of T. whipplei in the stools and saliva and bacteremia. CONCLUSIONS: Our findings suggest that T. whipplei is an agent of unexplained cold season fever with cough in rural West Africa.

Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases.

BACKGROUND. Blood culture-negative endocarditis (BCNE) may account for up to 31% of all cases of endocarditis. METHODS. We used a prospective, multimodal strategy incorporating serological, molecular, and histopathological assays to investigate specimens from 819 patients suspected of having BCNE. RESULTS. Diagnosis of endocarditis was first ruled out for 60 patients. Among 759 patients with BCNE, a causative microorganism was identified in 62.7%, and a noninfective etiology in 2.5%. Blood was the most useful specimen, providing a diagnosis for 47.7% of patients by serological analysis (mainly Q fever and Bartonella infections). Broad-range polymerase chain reaction (PCR) of blood and Bartonella-specific Western blot methods diagnosed 7 additional cases. PCR of valvular biopsies identified 109 more etiologies, mostly streptococci, Tropheryma whipplei, Bartonella species, and fungi. Primer extension enrichment reaction and autoimmunohistochemistry identified a microorganism in 5 additional patients. No virus or Chlamydia species were detected. A noninfective cause of endocarditis, particularly neoplasic or autoimmune disease, was determined by histological analysis or by searching for antinuclear antibodies in 19 (2.5%) of the patients. Our diagnostic strategy proved useful and sensitive for BCNE workup. CONCLUSIONS. We highlight the major role of zoonotic agents and the underestimated role of noninfective diseases in BCNE. We propose serological analysis for Coxiella burnetii and Bartonella species, detection of antinuclear antibodies and rheumatoid factor as first-line tests, followed by specific PCR assays for T. whipplei, Bartonella species, and fungi in blood. Broad-spectrum 16S and 18S ribosomal RNA PCR may be performed on valvular biopsies, when available.

Hepatitis E virus infection in sheltered homeless persons, France.

To determine the prevalence of hepatitis E virus (HEV) infection among sheltered homeless persons in Marseille, France, we retrospectively tested 490 such persons. A total of 11.6% had immunoglobulin (Ig) G and 2.5% had IgM against HEV; 1 person had HEV genotype 3f. Injection drug use was associated with IgG against HEV.

Tropheryma whipplei in children with gastroenteritis.

Tropheryma whipplei, which causes Whipple disease, is found in human feces and may cause gastroenteritis. To show that T. whipplei causes gastroenteritis, PCRs for T. whipplei were conducted with feces from children 2-4 years of age. Western blotting was performed for samples from children with diarrhea who had positive or negative results for T. whipplei. T. whipplei was found in samples from 36 (15%) of 241 children with gastroenteritis and associated with other diarrheal pathogens in 13 (33%) of 36. No positive specimen was detected for controls of the same age (0/47; p = 0.008). Bacterial loads in case-patients were as high as those in patients with Whipple disease and significantly higher than those in adult asymptomatic carriers (p = 0.002). High incidence in patients and evidence of clonal circulation suggests that some cases of gastroenteritis are caused or exacerbated by T. whipplei, which may be co-transmitted with other intestinal pathogens.

Testing for human papillomavirus and measurement of viral load of HPV 16 and 18 in self-collected vaginal swabs of women who do not undergo cervical cytological screening in Southern France.

Self-sampling using vaginal swabs could be a valuable alternative to screen for cervical cancer for women who do not attend regular cytological screening. The aim of this study was to determine the prevalence of high and low-risk HPV types and of HPV type 16 and 18 DNA load in self-collected vaginal swabs from 35- to 69-year-old Southern French women of low socioeconomic level or migrant populations who do not attend regular cervical screening. A good concordance (93.1%) was found between cervical brush and vaginal swabs in 29 samples. Self-collected vaginal swabs were examined from 120 women. HPV infection was found in 28 women (23.3%; median age 48 years), 17 (14.1%) of whom harbored high-risk HPV types. HPV type 16 was the high risk type found most frequently, followed by types 53, 31, 18, 58, and 66. The low-risk type detected most frequently was HPV type 6, followed by types 61, 70, and 81. The mean HPV 16 and 18 load was 6.3 log(10) copies/10(6) cells and 2.4 log(10) copies/10(6) cells, respectively. These results suggest that vaginal self-swabs can be a reliable tool for cervical cancer screening in non-attending and inadequately screened elderly women.

Contribution of a shelter-based survey for screening respiratory diseases in the homeless.

BACKGROUND: The homeless are at very high risk for both respiratory diseases and poor access to health care delivery systems. The aim of this study was to assess the contribution of a shelter-based survey to identify respiratory diseases in the homeless population in Marseilles, in order to further develop preventive interventions. METHODS: A prevalence survey of respiratory diseases was conducted in two homeless shelters in Marseilles, in February 2005. A multidisciplinary team including infectious diseases specialists, lung specialists, residents, nurses, physiotherapists and X-ray technicians visited the two shelters. Interview, physical examination, sputum sampling for Mycobacterium tuberculosis detection, nasal swabs for virus detection and chest X-rays were performed in shelters. Chest X-rays were subsequently analysed by a pneumonologist and subjects found to have radiological abnormalities were hospitalized for further investigations. RESULTS: Of the 221 homeless persons enrolled, 110/221 (50%) had at least one respiratory manifestations. Chest X-rays were abnormal in 14 persons. Active tuberculosis was diagnosed in two, influenza in two, respiratory syncytial virus infection in two, acute pneumonia in one, asthma in two, lung cancer in one, acute bronchitis in 23, chronic bronchitis in 42, and exacerbation of chronic obstructive pulmonary disease in 22 persons, respectively. CONCLUSION: Our shelter-based survey, including clinical evaluation and chest radiographic screening, shows that this approach can be useful to control and prevent respiratory diseases among the homeless. However, further studies are necessary to determine the magnitude of influenza in the homeless, the impact of influenza immunization and optimal frequency of interventions in shelters.