Spondylodiscitis due to Aerococcus urinae and literature review.

INTRODUCTION: Aerococccus urinae (AU) is a pathogen mainly identified in male urinary tract infections and responsible for bacteremia and endocarditis. To the best of our knowledge, there are only five patients with osteomyelitis due to AU described in the literature. All of them had urinary tract disease or systemic conditions such as diabetes, and two were associated with an endocarditis. CASE REPORT: We described the first case of isolated spondylodiscitis without general or local predisposing condition, excepted age > 65 years.

Clinical usefulness of 18F-FDG PET/CT for initial staging and assessment of treatment efficacy in patients with lymph node tuberculosis.

INTRODUCTION: Few studies have evaluated the promising role of 18F-fluoro-2-deoxy-D-glucose positron emission tomography (PET) and PET/computed tomography FDG PET/CT in evaluating and monitoring treatment response in patients with lymph node tuberculosis (LNTB). The aim of this clinical investigation was to assess the clinical usefulness of FDG PET/CT for initial tuberculosis staging and to determine the prognostic value of the decrease of 18F-FDG uptake during antibiotic treatment in LNTB patients. METHODS: We retrospectively reviewed 18 cases of LNTB admitted at a single center from 2004 to 2014. Medical records of patients who underwent two FDG PET/CT (>6 months interval), at initial staging and at the end of therapy were reviewed to determine the impact of FDG PET/CT on initial management of LNTB and response to therapy. Statistical analysis was performed using linear mixed-effects model. RESULTS: Thirteen cases of disseminated LNTB and five cases of localized LNTB were included in the study. Initial FDG PET/CT allowed guided biopsy for initial diagnosis in 5 patients and identified unknown extra-LN TB sites in 9 patients. Visual analysis follow-up of FDG PET/CT showed a complete metabolic response in 9/18 patients (all of whom were cured), a partial response in 7/18 (5 of whom were cured) and no response in 2/18 (all of whom were not cured). The semi-quantitative evaluation of 18F-FDG intensity decrease based on the maximum standardized uptake value (SUVmax), compared to targeted estimated decrease allowed to predict correctly a complete response to treatment in 14/18 cases. CONCLUSION: FDG PET/CT allows an accurate pre-therapeutic mapping of LNTB and helps for early TB confirmation. The SUVmax follow up is a potential tool for monitoring the treatment response.

First case of amebic liver abscess 22 years after the first occurrence.

A 72-year-old man consulted in November 2012 for abdominal pain in the right upper quadrant. The patient had a history of suspected hepatic amebiasis treated in Senegal in 1985 and has not traveled to endemic areas since 1990. Abdominal CT scan revealed a liver abscess. At first, no parasitological tests were performed and the patient was treated with broad-spectrum antibiotics. Only after failure of this therapy, serology and PCR performed after liver abscess puncture established the diagnosis of hepatic amebiasis. The patient was treated with metronidazole and tiliquinol-tilbroquinol. Amebic liver abscess is the most frequent extra-intestinal manifestation. Hepatic amebiasis 22 years after the last visit to an endemic area is exceptional and raises questions on the mechanisms of latency and recurrence of these intestinal protozoan parasites.

[Lyme borreliosis and co-infections. Place of Anaplasma phagocytophilum and Bartonella henselae]. / Borréliose de Lyme et co-infections. Place d'Ana- plasma phagocytophilum et de Bartonella henselae.

Lyme borreliosis (LB) is certainly the most common infection transmitted through the bite of Ixodes in Northern Hemisphere. These ticks are also able to transmit other microorganisms such as the bacteria Anaplasma phagocytophilum (Ap) and Bartonella henselae (Bh), with the latter discovered fairly recently, leading to diferent clinical presentations often close to those of LB. The aim of this study was to evaluate the frequency of co-infection by either of these bacteria in patients with LB, particularly when a treatment with beta-lactam antibiotic was only partially effective. Of these patients, on the basis of serological data, 8.07% were simultaneously contaminated by Bh, 6.83% by Ap and 4.96% were co-infected by Bh and Ap. Since the choice of an antibiotic should take into account the specificities of these germs and especially their intracellular proliferation, these results should be considered in selecting treatment.

Immunoglobulin deficiency in patients with Streptococcus pneumoniae or Haemophilus influenzae invasive infections.

OBJECTIVES: Immunoglobulin (Ig) deficiency is a well-known risk factor for Streptococcus pneumoniae or Haemophilus influenzae infections and noteworthy invasive diseases. However, the proportion of these deficiencies in cases of invasive disease is unknown. The objective of this study was to evaluate the rate of Ig deficiency in cases of invasive disease. METHODS: A prospective study was conducted from January 2008 to October 2010 in two French hospitals. Measurement of Ig levels was carried out in patients hospitalized for invasive diseases. RESULTS: A total of 119 patients were enrolled in the study, with nine cases of H. influenzae and 110 cases of S. pneumoniae invasive disease. There were 18 cases of meningitis, 79 of invasive pneumonia, and 22 other invasive diseases. Forty-five patients (37.8%) had an Ig abnormality, 37 of whom had an Ig deficiency (20 IgG <6g/l, four isolated IgA <0.7g/l, and 13 isolated IgM <0.5g/l), while eight had an elevated monoclonal paraprotein. Nineteen of these 45 patients had a clearly defined Ig abnormality, with five primary deficiencies (three common variable immunodeficiencies and two complete IgA deficiencies) and 14 secondary deficiencies, mainly lymphoproliferative disorders. All these deficiencies were either not known or not substituted. CONCLUSIONS: Humoral deficiency is frequent in patients with S. pneumoniae or H. influenzae invasive disease and Ig dosage should be proposed systematically after such infections.

In vitro activity of daptomycin against Enterococcus faecalis under various conditions of growth-phases, inoculum and pH.

Enterococcus faecalis (E. faecalis) has become a major leading cause of nosocomial endocarditis. Treatment of such infections remains problematic and new therapeutic options are needed. Nine E. faecalis strains were tested: six obtained from patients presenting endocarditis, one with isolated bacteremia, and two reference strains. Antibiotics included daptomycin, alone or in combination, linezolid, tigecycline, rifampicin, gentamicin, teicoplanin, ceftriaxone and amoxicillin. Time-kill studies included colony counts at 1, 4 and 24 h of incubation. Significant bactericidal activity was defined as a decrease of ≥3log10CFU/ml after 24 h of incubation. Antibiotics were tested at a low (10(6) CFU/ml) and high (10(9) CFU/ml) inoculum, against exponential- and stationary-phase bacteria. We also performed time kill studies of chemically growth arrested E. faecalis. Various pH conditions were used during the tests. In exponential growth phase and with a low inoculum, daptomycin alone at 60 µg/ml and the combination amoxicillin-gentamicin both achieved a 4-log10 reduction in one hour on all strains. In exponential growth phase with a high inoculum, daptomycin alone was bactericidal at a concentration of 120 µg/ml. All the combinations tested with this drug were indifferent. In stationary phase with a high inoculum daptomycin remained bactericidal but exhibited a pH dependent activity and slower kill rates. All combinations that did not include daptomycin were not bactericidal in conditions of high inoculum, whatever the growth phase. The results indicate that daptomycin is the only antibiotic that may be able of overcoming the effects of growth phase and high inoculum.

Primary musculoskeletal hydatid cyst of the thigh: Diagnostic and curative challenge for an unusual localization.

Primary muscular echinococcosis is an uncommon localization of hydatid cysts. The nonspecific clinical presentation and possible post-therapeutic complications lead to problems for the diagnosis of this infection and the support of the patient. The authors describe an unusual case of double hydatid cyst of the vastus intermedius muscle. After a precise preoperative evaluation based on clinical, radiological and biological examinations, a surgical excision by pericystectomy combined with perioperative chemotherapy enabled the authors to treat the patient and to prevent postoperative complications. The diagnostic tools and the treatment of this particular type of echinococcosis are discussed.

L'échinococcose musculaire primaire est un foyer inhabituel des kystes hydatiques. La présentation clinique non spécifique et les complications post-thérapeutiques éventuelles peuvent s'associer à des difficultés à diagnostiquer cette infection et à soutenir le patient. Les auteurs décrivent un cas inhabituel de double kyste hydatique du muscle vaste intermédiaire. Après une évaluation préopératoire détaillée fondée sur des examens clinique, radiologique et biologique, les auteurs ont traité le patient en procédant à une excision chirurgicale par périkystectomie conjuguée à une chimiothérapie périopératoire, ce qui a permis d'éviter les complications postopératoires. Ils présentent également les outils diagnostiques et le traitement de ce type d'échinococcose.

Cerebral vasculitis associated with Schistosoma mansoni infection.

BACKGROUND: Cerebral involvement in schistosomiasis is not rare, but it is underdiagnosed because of the lack of clinical suspicion and the frequency of asymptomatic forms. Neurologic complications are generally supported by granuloma formation around ectopic eggs which have migrated to the brain. Moreover, vascular lesions and cerebral arteritis have been well documented in histopathological studies. Nevertheless, cerebral vasculitis in later stages of the Schistosoma mansoni infection have not yet been described in living subjects. CASE PRESENTATION: A 28-year-old french woman had a stroke linked with cerebral vasculitis, 6 monthes after returning from Burkina-Faso. At the same time, a S. mansoni disseminated infection was diagnosed. She suffered from a new stroke after undertaking praziquantel therapy, which lead us to associate the S. mansoni infection and cerebral vasculitis. CONCLUSION: This is the first report of such association, since cerebral vasculitis has never been described in later stages of the S. mansoni infection. Although the causal link between the two pathologies could not be proved, we suggest that S. mansoni is able to cause severe vascular damage in cerebral vessels. Schistosomiasis must be investigated in the event of a brain infarct in young people, particularly in patients originating or returning from an endemic area.

Impact of malnutrition and social determinants on survival of HIV-infected adults starting antiretroviral therapy in resource-limited settings.

OBJECTIVES: Determining the impact of malnutrition, anaemia and social determinants on survival once starting antiretroviral therapy (ART) in a cohort of HIV-infected adults in a rural HIV care centre in Sihanoukville, Cambodia. METHODS: Retrospective and descriptive cohort study of adults starting ART between December 2004 and July 2009. We used the Kaplan-Meier and Cox regression survival analyses to identify predictors of death. RESULTS: Out of 1002 patients, 49.7% were men; median age was 40; median time of follow-up was 2.4 years and 10.4% died during the follow-up. At baseline, median CD4 cell count was 83 cells/µl, 79.9% were at WHO stage III or IV. In multivariate analysis, malnutrition appeared to be a strong and independent risk factor of death; 11.2% had a BMI less than 16 kg/m and hazard ratio was 6.97 [95% confidence interval (CI), 3.51-13.89], 21.5% had a BMI between 16 and 18 kg/m and hazard ratio was 2.88 (95% CI, 1.42-5.82), 30.8% had a BMI between 18 and 20 kg/m and hazard ratio was 2.18 (95% CI, 1.09-4.36). Severe anaemia (haemoglobin≤8.4 g/dl) and CD4 cell count below 100 cells/µl also predicted mortality, hazard ratio were 2.25 (95% CI, 1.02-4.34) and 2.29 (95% CI, 1.01-2.97), respectively. Social determinants were not significantly associated with death in univariate analysis. CONCLUSION: Malnutrition and anaemia are strong and independent prognostic factors at the time of starting ART. Nutritional cares are essential for the clinical success of HIV programs started in developing countries.

Babesiosis in immunocompetent patients, Europe.

We report 2 cases of babesiosis in immunocompetent patients in France. A severe influenza-like disease developed in both patients 2 weeks after they had been bitten by ticks. Diagnosis was obtained from blood smears, and Babesia divergens was identified by PCR in 1 case. Babesiosis in Europe occurs in healthy patients, not only in splenectomized patients.

Case report: rectal perforation caused by Schistosoma haematobium.

A 31-year-old woman from Cameroon was admitted to the University of Strasbourg Hospital in December 2007 with pelvic pain and fever that developed over three days. Her condition rapidly worsened and she underwent emergency exploratory celioscopy. Surgeons found peritoneal and retrouterine abscesses. The high rectum had a 4-cm perforation with infiltrated, friable, and irregular edges. A biopsy specimen of this pseudotumoral specimen showed many Schistosoma haematobium eggs with an inflammatory reaction surrounding the eggs. The patient was treated with praziquantel (40 mg/kg/day) for 5 days and a 4-week course of antibiotic therapy. Her progress was good and digestive continuity surgery was performed four months later. Schistosomiasis frequently involves rectal mucosa, but perforation is unusual. Our review of the literature found only two cases of colon perforation associated with S. mansoni infection. To our knowledge, this is the first case of rectal perforation caused by S. haematobium described in the literature.

Minocycline-induced hypersensitivity syndrome presenting with meningitis and brain edema: a case report.

BACKGROUND: Hypersentivity Syndrome (HS) may be a life-threatening condition. It frequently presents with fever, rash, eosinophilia and systemic manifestations. Mortality can be as high as 10% and is primarily due to hepatic failure. We describe what we believe to be the first case of minocycline-induced HS with accompanying lymphocytic meningitis and cerebral edema reported in the literature. CASE PRESENTATION: A 31-year-old HIV-positive female of African origin presented with acute fever, lymphocytic meningitis, brain edema, rash, eosinophilia, and cytolytic hepatitis. She had been started on minocycline for inflammatory acne 21 days prior to the onset of symptoms. HS was diagnosed clinically and after exclusion of infectious causes. Minocycline was withdrawn and steroids were administered from the second day after presentation because of the severity of the symptoms. All signs resolved by the seventh day and steroids were tailed off over a period of 8 months. CONCLUSION: Clinicians should maintain a high index of suspicion for serious adverse reactions to minocycline including lymphocytic meningitis and cerebral edema among HIV-positive patients, especially if they are of African origin. Safer alternatives should be considered for treatment of acne vulgaris. Early recognition of the symptoms and prompt withdrawal of the drug are important to improve the outcome.

Tick-borne encephalitis in eastern France.

Each y a few cases of TBE infection are described in Alsace, France which lies at the occidental limit of the endemic zone of tick-borne encephalitis (TBE). Hence we carried out a retrospective epidemiological and clinical study of TBE infection in Alsace. Data were collected from serological results sent to the Institut de Virologie (Université Louis Pasteur) in Strasbourg. All samples positive for specific IgM against TBE were retained. The physician in charge of each patient was asked to provide clinical, epidemiological and biological data and with his agreement the medical file was referred to us. Since 1968, 64 cases of TBE infection, occurring between April and November, had been described. In 56% of cases, flu-like symptoms preceded neurological symptoms. Most patients had meningitis (54%) or meningoencephalitis (34%). There was no death due to TBE. Two areas were more highly endemic for the disease: the Guebwiller valley in low mountain country and the Neuhof forest, near Strasbourg in the plain of Alsace. In the last 2 y of the study, a third zone seemed to emerge, in the Munster valley. This epidemiological survey revealed the existence in Alsace of 2 endemic zones of TBE with a third zone possibly emerging in the last few y. The survey must be continued to follow the evolution of the disease.

Diagnosis of cat scratch disease with detection of Bartonella henselae by PCR: a study of patients with lymph node enlargement.

Cat scratch disease (CSD) is mostly due to Bartonella henselae after inoculation of the organism through a skin injury. Since the causative bacteria cannot be easily cultured from human lymph node samples, the diagnosis usually relies on epidemiological, clinical, histological, and serological criteria (classical criteria). A study was performed to determine the diagnostic value of PCR analysis for the detection of B. henselae for the diagnosis of CSD and its place in the diagnostic strategy alongside the classical criteria. Over a 7-year period, lymph node biopsy specimens or cytopunctures from 70 patients were systematically tested by PCR for the presence of B. henselae DNA (htrA gene) in the Bacteriology Laboratory of the Hôpitaux Universitaires de Strasbourg. Serological testing by an immunofluorescence assay for B. henselae antibodies was also performed for each patient, and clinical, epidemiological, and histological data were collected. The patients were then divided into two groups according to the number of positive diagnostic criteria for CSD: 29 patients with definite CSD (two or more classical criteria) and 15 patients with possible CSD (less than two classical criteria). The remaining 26 patients for whom another diagnosis was retained were used as a control group. Among all criteria, PCR analysis had the best specificity (100%). The PCR assay for B. henselae was positive for 22 (76%; 95% confidence interval [CI95], 56.5 to 89.7%) of the 29 definite CSD patients and 3 (20%; CI95, 4.3 to 48.1%) of the 15 possible CSD patients. We then studied combinations of diagnostic criteria, including B. henselae PCR analysis. The best diagnostic performance was observed if at least two criteria were present among serologic, epidemiologic, histological, and molecular criteria.

Healthcare-associated Staphylococcus aureus bacteremia and the risk for methicillin resistance: is the Centers for Disease Control and Prevention definition for community-acquired bacteremia still appropriate?

OBJECTIVE: To evaluate a new classification for bloodstream infections that differentiates hospital acquired, healthcare associated, and community acquired in patients with blood cultures positive for Staphylococcus aureus. DESIGN: Prospective, observational study. SETTING: Three tertiary-care, university-affiliated hospitals in Dublin, Ireland, and Strasbourg, France. PATIENTS: Two hundred thirty consecutive patients older than 18 years with blood cultures positive for S. aureus. METHODS: S. aureus bacteremia (SAB) was defined as hospital acquired if the first positive blood culture was performed more than 48 hours after admission. Other SABs were classified as healthcare associated or community acquired according to the definition proposed by Friedman et al. When available, strains of methicillin-resistant Staphylococcus aureus (MRSA) were analyzed by pulsed-field gel electrophoresis (PFGE). RESULTS: Eighty-two patients were considered as having community-acquired bacteremia according to the Centers for Disease Control and Prevention (CDC) classification. Of these 82 patients, 56% (46) had healthcare-associated SAB. MRSA prevalence was similar in patients with hospital-acquired and healthcare-associated SAB (41% vs 33%; P > .05), but significantly lower in the group with community-acquired SAB (11%; P < .03). PFGE of MRSA strains showed that most community-acquired and healthcare-associated MRSA strains were similar to hospital-acquired MRSA strains. On multivariate analysis, Friedman's classification was more effective than the CDC classification for predicting MRSA. CONCLUSION: These results support the call for a new classification for community-acquired bacteremia that would account for healthcare received outside the hospital by patients with SAB.