Systemic vasculitis diagnosed during the post-partum period: case report and review of the literature.

INTRODUCTION: The vasculitis diagnosed specifically in the post-partum period are less well known. We report here such a case followed by a descriptive review of the literature. CASE REPORT: A 25 year-old French nurse reported abrupt-onset musculoskeletal pain 15 days after delivery of her first infant. Her first pregnancy was uneventful. The physical examination yielded only bilateral conjunctivitis and purpuric eruption of lower limbs, and complementary investigations evidenced pulmonary renal syndrome in connection with the diagnosis of Granulomatosis with Polyangiitis. METHODS: We screened previous articles in Medline database using keywords (i) "post-partum" or "puerperium" (ii)"peripartum" (iii) "pregnancy" associated with "vasculitis". Full texts were obtained from case reports or cases series whose title or abstract included keywords of interest (or synonyms). These references were secondarily excluded if the diagnosis of vasculitis was not confirmed or made before or more than 6 months after delivery and if vasculitis occurred only in the new born or affected only the cerebral vasculature or the retina. RESULTS: Fifty-six cases of vasculitis diagnosed in the post-partum period were included, 50 (89.3%) were secondary to an immunological process and 44 corresponded to primary vasculitis, 4 were secondary to Systemic Lupus Erythematosus, 1 to cryoglobulinaemia and 1 to cryoglobulinaemia associated with inflammatory bowel disease. The main primary vasculitis diagnosed were Takayasu Arteritis (n = 10), Eosinophilic granulomatosis with polyangiitis (n = 9), Granulomatosis with Polyangiitis (n = 7), Periarteritis Nodosa (n = 5) and Behcet's disease (n = 4). The first symptom occurred before delivery in 26 (59.1%) and maternal death occurred in 4 (9.1%) out of the 44 primary vasculitis cases. CONCLUSION: The vasculitis diagnosed in the post-partum period were mainly primary vasculitis among patients in whom the diagnosis had not been made during pregnancy. In less than half of cases and as described in ours, there were no reported symptoms before delivery. Therefore, the physicians should pay attention to symptoms and keep a high degree of suspicion for vasculitis before as well as after delivery.

Alveolar hemorrhage due to marijuana smoking using water pipe made with plastic bottle: case report and narrative review of the literature.

INTRODUCTION: We described a case of alveolar hemorrhage (AH) after marijuana smoking using a water pipe made with plastic bottle (bong) before making a narrative review of the literature. CASE REPORT: A 19-year-old male was admitted for hemoptysis and dyspnea evolving since the previous day. He smoked marijuana ten times a day using bongs. Computed tomography scan of the chest (chest CT-scan) evidenced ground glass opacities involving upper lobes with crazy-paving pattern. Bronchoalveolar lavage (BAL) yielded fluid becoming progressively bloody suggestive of AH. Screening of drug metabolites ruled out the presence of cocaine degradation products. Treatment with prednisone was prescribed and oxygen requirements decreased rapidly. The patient accepted to stop bongs, but kept on smoking marijuana using joints. He was asymptomatic 2 months later; all ground glass opacities had vanished. REVIEW OF THE LITERATURE: Four cases described exactly the same circumstances as ours. All were young male patients containing ground glass opacities with diffuse or bilateral pattern in their chest CT-scan. The explanation suggested by the authors of these cases was the potential concomitant inhalation of acid anhydrides derived from use of heated plastic bottle. No acid anhydrides were experimentally evidenced after thermodesorption of heated polyethylene terephthalate (PET) (in which a majority of plastic bottles are made) we performed, but other compounds were. E-cigarette, or vaping, product use-associated lung injuries cases share some chest CT-scan patterns with those of AH following bong use and we tried to draw a parallel between these two latter before discussing a physiopathological hypothesis.

Case Report: Could Artemisinin-Based Combination Therapy Prevent Occupational Malaria following Blood Exposure?

Postexposure prophylaxis using artemisinin-based combination therapy (ACT) was prescribed to a malaria-naive nurse who experienced an injury with a hollow needle previously used on a patient admitted for severe imported Plasmodium falciparum malaria (blood parasitemia 10.8%). Artemether-lumefantrine, four tablets twice daily for 3 days, was started 12 hours after exposure, and no side effects were reported. During the six following months, she only developed one episode of fever that was associated with pyelonephritis. Biological follow-up, based on blood smears, molecular biology, and serology, did not evidence P. falciparum malaria. This case suggests that ACT can prevent occupational P. falciparum malaria following needle-stick injury. We found evidence of only one other unpublished similar case where a Turkish resident doctor did not develop malaria after postexposure prophylaxis using ACT. Such a prophylaxis could be prescribed not only in case of occupational exposure to Plasmodium spp. in nonvector-borne laboratory-acquired infections but also following blood exposure in healthcare setting.

Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?

PURPOSE: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG. PATIENTS AND METHODS: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model. RESULTS: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0-87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7-50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0-38.0] versus 5.0[3.0-21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0-134.0] versus 9.0 [7.0-51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64-80.75], OR 4.64 [1.61-13.34] and OR 1.27 [1.02-1.58], respectively). CONCLUSION: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.

Vasculitides and glomerulonephritis associated with Staphylocococcus aureus infective endocarditis: cases reports and mini-review of the literature.

We reported two cases of Staphylococcus aureus Infective Endocarditis associated with vasculitides and glomerulonephritis respectively, before conducting an online search of previously published similar cases reports. Twenty five references were selected: 15 cases of glomerulonephritis; 2 cases of vasculitis and 8 cases involving both glomerulonephritis and vasculitis. Vasculitides and glomerulonephritis associated with Staphylococcus aureus definite Infective Endocarditis have been reported since 1976. All cases except one described clinical symptoms occurring before or during initial antibiotics treatment. Except kidney, organs that were more frequently affected by vasculitis process were skin, gastrointestinal tract and peripheral nerve and the vessels involved were small to medium size vessels. When antineutrophil cytoplasmic antibodies were evidenced (6 out of the 25 cases (24%)), kidney was the most frequently affected organ. The most commonly observed pattern in Kidney biopsy was membranoproliferative glomerulonephritis with endocapillary proliferation sometimes associated with extra capillary crescents, whether or not antineutrophil cytoplasmic antibodies were evidenced. Right-sided Infective Endocarditis (especially in intravenous drug users) were overrepresented (14 of the 25 cases (56.0%)) in this review. Besides antibiotics, corticosteroids were the most frequently prescribed immunosuppressive treatment both for vasculitides or glomerulonephritis. KEY MESSAGES Vasculitides and glomerulonephritis associated with Staphylococcus aureus definite Infective Endocarditis have been reported since 1976. Except kidney, organs that were more frequently affected (by small to medium size vessel vasculitis) were skin, gastrointestinal tract and peripheral nerve. The most commonly observed pattern in Kidney biopsy was membranoproliferative glomerulonephritis with endocapillary proliferation and right-sided Infective Endocarditis (especially in intravenous drug users) were overrepresented in this review.

Enterovirus Persistence in Cardiac Cells of Patients With Idiopathic Dilated Cardiomyopathy Is Linked to 5' Terminal Genomic RNA-Deleted Viral Populations With Viral-Encoded Proteinase Activities.

BACKGROUND: Group B enteroviruses are common causes of acute myocarditis, which can be a precursor of chronic myocarditis and dilated cardiomyopathy, leading causes of heart transplantation. To date, the specific viral functions involved in the development of dilated cardiomyopathy remain unclear. METHODS: Total RNA from cardiac tissue of patients with dilated cardiomyopathy was extracted, and sequences corresponding to the 5' termini of enterovirus RNAs were identified. After next-generation RNA sequencing, viral cDNA clones mimicking the enterovirus RNA sequences found in patient tissues were generated in vitro, and their replication and impact on host cell functions were assessed on primary human cardiac cells in culture. RESULTS: Major enterovirus B populations characterized by 5' terminal genomic RNA deletions ranging from 17 to 50 nucleotides were identified either alone or associated with low proportions of intact 5' genomic termini. In situ hybridization and immunohistological assays detected these persistent genomes in clusters of cardiomyocytes. Transfection of viral RNA into primary human cardiomyocytes demonstrated that deleted forms of genomic RNAs displayed early replication activities in the absence of detectable viral plaque formation, whereas mixed deleted and complete forms generated particles capable of inducing cytopathic effects at levels distinct from those observed with full-length forms alone. Moreover, deleted or full-length and mixed forms of viral RNA were capable of directing translation and production of proteolytically active viral proteinase 2A in human cardiomyocytes. CONCLUSIONS: We demonstrate that persistent viral forms are composed of B-type enteroviruses harboring a 5' terminal deletion in their genomic RNAs and that these viruses alone or associated with full-length populations of helper RNAs could impair cardiomyocyte functions by the proteolytic activity of viral proteinase 2A in cases of unexplained dilated cardiomyopathy. These results provide a better understanding of the molecular mechanisms that underlie the persistence of EV forms in human cardiac tissues and should stimulate the development of new therapeutic strategies based on specific inhibitors of the coxsackievirus B proteinase 2A activity for acute and chronic cardiac infections.

Enterovirus but not Parvovirus B19 is associated with idiopathic dilated cardiomyopathy and endomyocardial CD3, CD68, or HLA-DR expression.

We assessed Enterovirus (EV) &Parvovirus B19 (PVB19) genomes and CD3, CD68&HLA-DR detection in dilated cardiomyopathies (DCM). EV&PVB19 genomes and CD3, CD68&HLA-DR were detected by PCR and immunohistochemistry assays in 115 endomyocardial biopsies obtained in 13 idiopathic DCM (iDCM) and 10 explained DCM (eDCM) patients. Results were compared with those of 47 atrial surgical samples (47 surgery controls) and 22 autoptic cardiac samples (11 healthy heart controls) (2008-2014, Reims, France). EV was detected in 23.1% of iDCM patients but not in eDCM and controls (P = 0.003) (viral load 803 copies/µg). PVB19 was detected in 76.9%, 80.0%, 63.6% and 78.2% of iDCM, eDCM, healthy heart and surgery controls (P = 0.99) with a mean viral load of 413, 346, 1,428, and 71 copies/µg. CD3, CD68 or HLA-DR were detected in 100 and 50% of EV and PVB19 "mono-infected" iDCM patients. EV was exclusively detected in iDCM cases in association with CD3, CD68, or HLA-DR indicating that EV could be an etiological cause in a subset of iDCM cases. By contrast the equal frequent detection of PVB19 in iDCM cases and controls without association with CD3, CD68, or HLA-DR suggested that PVB19 could be a bystander in many DCM cases. J. Med. Virol. 89:55-63, 2017. © 2016 Wiley Periodicals, Inc.

Time interval between infective endocarditis first symptoms and diagnosis: relationship to infective endocarditis characteristics, microorganisms and prognosis.

OBJECTIVE: To analyze the characteristics and outcome of infective endocarditis (IE) according to the time interval between IE first symptoms and diagnosis. METHODS: Among the IE cases of a French population-based epidemiological survey, patients having early-diagnosed IE (diagnosis of IE within 1 month of first symptoms) were compared with those having late-diagnosed IE (diagnosis of IE more than 1 month after first symptoms). RESULTS: Among the 486 definite-IE, 124 (25%) had late-diagnosed IE whereas others had early-diagnosed IE. Early-diagnosed IE were independently associated with female gender (OR = 1.8; 95% CI [1.0-3.0]), prosthetic valve (OR= 2.6; 95% CI [1.4-5.0]) and staphylococci as causative pathogen (OR = 3.7; 95% CI [2.2-6.2]). Cardiac surgery theoretical indication rates were not different between early and late-diagnosed IE (56.3% vs 58.9%), whereas valve surgery performance was lower in early-diagnosed IE (41% vs 53%; p = .03). In-hospital mortality rates were higher in early-diagnosed IE than in late-diagnosed IE (25.1% vs 16.1%; p < .001). CONCLUSIONS: The time interval between IE first symptoms and diagnosis is closely related to the IE clinical presentation, patient characteristics and causative microorganism. Better prognosis reported in late-diagnosed IE may be related to a higher rate of valvular surgery. KEY MESSAGES Infective endocarditis, which time interval between first symptoms and diagnosis was less than one month, were mainly due to Staphylococcus aureus in France. Staphylococcus aureus infective endocarditis were associated with septic shock, transient ischemic attack or stroke and higher mortality rates than infective endocarditis due to other bacteria or infective endocarditis, which time interval between first symptoms and diagnosis was more than one month. Infective endocarditis, which time interval between first symptoms and diagnosis was more than one month, were accounting for one quarter of all infective endocarditis in our study and were associated with vertebral osteomyelitis and a higher rate of cardiac surgery performed for hemodynamic indication than other infective endocarditis.

Cavernous sinus thrombosis secondary to aspergillus granuloma: A case report and review of the literature.

Cavernous sinus thrombosis is a rare but serious complication of sphenoid aspergillosis. The rarity of this pathology makes its diagnostic very difficult on a clinical, biological and radiological sense. The authors present a case of cavernous sinus thrombosis with ipsilateral internal carotid artery thrombosis secondary to a non-invasive sphenoid aspergillosis in an immunocompetent host, responsible of a cavernous syndrome associated to a Claude Bernard Horner syndrome. One year after surgery, the patient is still asymptomatic without recurrence. Diagnostic modalities are detailed and several management of this pathology are compared. Surgery is essential in a diagnostic and therapeutic sense. There is no evidence of the interest of adjuvant therapies such as antibiotic and anticoagulation. Concerning the antifungal treatment, the attitude towards a non-invasive sphenoid aspergillosis in an immunocompetent host is unclear.

Rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host.

BACKGROUND: The rare descriptions, in the literature, of ocular infections due to Pasteurella multocida include: endophtalmitis, keratitis and corneal ulcers, Parinaud's oculoglandular syndrome, and conjunctivitis. Here, we report a rare case of rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host. CASE PRESENTATION: A 69-year-old, Caucasian male was referred to our department with purulent conjunctivitis, occurring five days after chemotherapy for an angioimmunoblastic-T-cell-lymphoma, and thirty-three hours after being struck in his right eye by his sneezing Dachshund dog. Physical examination revealed purulent conjunctivitis of the right eye associated with inflammatory edema of both lids. Direct bacteriological examination of conjunctival secretions showed gram-negative bacilli and regular, grey non-hemolytic colonies appearing the next day on blood agar. The oxidase test was positive for these colonies. An antibiotherapy associating intravenous amoxicillin and amoxicillin/clavulanate was administered. The outcome was favorable in the next three days allowing discharge of the patient with amoxicillin (2 g tid per os). CONCLUSION: This case report may be of interest for infectious diseases, ophthalmology or oncology specialists, especially nowadays with chemotherapy being administered in day care centres, where unusual home pathogens can be encountered in health related infections. In this case, previous animal contact and conjunctival samples showing Enterobacteriaceae like colonies with positive oxidase test were two important clues which could help clinicians to make the diagnosis of Pasteurella conjunctivitis in every day practice.

Virological diagnosis of central nervous system infections by use of PCR coupled with mass spectrometry analysis of cerebrospinal fluid samples.

Viruses are the leading cause of central nervous system (CNS) infections, ahead of bacteria, parasites, and fungal agents. A rapid and comprehensive virologic diagnostic testing method is needed to improve the therapeutic management of hospitalized pediatric or adult patients. In this study, we assessed the clinical performance of PCR amplification coupled with electrospray ionization-time of flight mass spectrometry analysis (PCR-MS) for the diagnosis of viral CNS infections. Three hundred twenty-seven cerebrospinal fluid (CSF) samples prospectively tested by routine PCR assays between 2004 and 2012 in two university hospital centers (Toulouse and Reims, France) were retrospectively analyzed by PCR-MS analysis using primers targeted to adenovirus, human herpesviruses 1 to 8 (HHV-1 to -8), polyomaviruses BK and JC, parvovirus B19, and enteroviruses (EV). PCR-MS detected single or multiple virus infections in 190 (83%) of the 229 samples that tested positive by routine PCR analysis and in 10 (10.2%) of the 98 samples that tested negative. The PCR-MS results correlated well with herpes simplex virus 1 (HSV-1), varicella-zoster virus (VZV), and EV detection by routine PCR assays (kappa values [95% confidence intervals], 0.80 [0.69 to 0.92], 0.85 [0.71 to 0.98], and 0.84 [0.78 to 0.90], respectively), whereas a weak correlation was observed with Epstein-Barr virus (EBV) (0.34 [0.10 to 0.58]). Twenty-six coinfections and 16 instances of uncommon neurotropic viruses (HHV-7 [n = 13], parvovirus B19 [n = 2], and adenovirus [n = 1]) were identified by the PCR-MS analysis, whereas only 4 coinfections had been prospectively evidenced using routine PCR assays (P < 0.01). In conclusion, our results demonstrated that PCR-MS analysis is a valuable tool to identify common neurotropic viruses in CSF (with, however, limitations that were identified regarding EBV and EV detection) and may be of major interest in better understanding the clinical impact of multiple or neglected viral neurological infections.

Coagulase-negative Staphylococcus bacteraemia accounts for one third of Staphylococcus bacteraemia in a French university hospital.

BACKGROUND: We sought to determine the epidemiological patterns of Staphylococcus bacteraemia, with a focus on the proportion of coagulase-negative Staphylococcus (CoNS) as compared to Staphylococcus aureus bacteraemia, and the prognosis. METHODS: All patients with significant Staphylococcus bacteraemia at the university hospital in Reims in 2008 were included in the study. Data were retrieved retrospectively from the patient records using a standardized case investigation form. Quantitative variables were compared using the Mann-Whitney U-test and qualitative variables were compared using Fisher's exact test or Pearson's Chi-square test, as appropriate. Bivariate logistic regression was performed on both S. aureus and CoNS bacteraemia. All variables with a p-value of < 0.15 were entered into a multiple logistic regression model. RESULTS: CoNS represented 31.6% of all strains isolated. The methicillin resistance rate was higher in CoNS (66.1%) than in S. aureus (19.1%) (p < 0.0001). CoNS were more frequently associated with intravascular catheters and neoplastic disease, whereas S. aureus was associated with chronic renal failure (p < 0.0001) and diabetes mellitus (p = 0.004). Mortality was 30.7% for S. aureus and 19.6% for CoNS bacteraemia (p = 0.12). Methicillin resistance was not associated with mortality (p = 0.99). Factors independently associated with mortality in CoNS and S. aureus bacteraemia were age and acute renal failure. The presence of severe sepsis/septic shock was only associated with mortality in S. aureus bacteraemia. CONCLUSIONS: CoNS represent one third of Staphylococcus bacteraemia. The mortality difference between CoNS and S. aureus bacteraemia was not statistically significant. Acute renal failure is associated with mortality in both S. aureus and CoNS bacteraemia.