Hepatic Brucelloma Diagnosis and Long-Term Treatment, France.

We report a case of hepatic brucelloma in France. This diagnosis may be suspected in any patient who has a liver abscess after traveling to a brucellosis-endemic area. Brucella spp. may be detected by PCR in the liver tissue or suppuration. Abscess drainage and prolonged antimicrobial therapy help achieve healing.

A 1-Year Prospective French Nationwide Study of Emergency Hospital Admissions in Children and Adults with Primary Immunodeficiency.

PURPOSE: Patients with primary immunodeficiency (PID) are at risk of serious complications. However, data on the incidence and causes of emergency hospital admissions are scarce. The primary objective of the present study was to describe emergency hospital admissions among patients with PID, with a view to identifying "at-risk" patient profiles. METHODS: We performed a prospective observational 12-month multicenter study in France via the CEREDIH network of regional PID reference centers from November 2010 to October 2011. All patients with PIDs requiring emergency hospital admission were included. RESULTS: A total of 200 admissions concerned 137 patients (73 adults and 64 children, 53% of whom had antibody deficiencies). Thirty admissions were reported for 16 hematopoietic stem cell transplantation recipients. When considering the 170 admissions of non-transplant patients, 149 (85%) were related to acute infections (respiratory tract infections and gastrointestinal tract infections in 72 (36%) and 34 (17%) of cases, respectively). Seventy-seven percent of the admissions occurred during winter or spring (December to May). The in-hospital mortality rate was 8.8% (12 patients); death was related to a severe infection in 11 cases (8%) and Epstein-Barr virus-induced lymphoma in 1 case. Patients with a central venous catheter (n = 19, 13.9%) were significantly more hospitalized for an infection (94.7%) than for a non-infectious reason (5.3%) (p = 0.04). CONCLUSION: Our data showed that the annual incidence of emergency hospital admission among patients with PID is 3.4%. The leading cause of emergency hospital admission was an acute infection, and having a central venous catheter was associated with a significantly greater risk of admission for an infectious episode.

mcr-1 Colistin Resistance in ESBL-Producing Klebsiella pneumoniae, France.

We report intestinal carriage of an extended-spectrum ß-lactamase-producing Klebsiella pneumoniae strain with high-level resistance to colistin (MIC 24 mg/L) in a patient in France who had been hospitalized for fungal meningitis. The strain had the mcr-1 plasmid gene and an inactivated mgrB gene, which are associated with colistin resistance.

Treatment of tularemia in pregnant woman, France.

A pregnant woman who had oropharyngeal tularemia underwent treatment with azithromycin and lymph node resection and recovered without obstetrical complication or infection in the child. Azithromycin represents a first-line treatment option for tularemia during pregnancy in regions where the infecting strains of Francisella tularensis have no natural resistance to macrolides.

Clinical, functional and genetic analysis of twenty-four patients with chronic granulomatous disease - identification of eight novel mutations in CYBB and NCF2 genes.

Chronic granulomatous disease is an inherited disorder in which phagocytes lack a functional NADPH oxidase and cannot produce superoxide anions. The most common form is caused by mutations in CYBB encoding gp91phox. We investigated 24 CGD patients and their families. Twenty-one mutations in CYBB were classified as X91(0), X91(+) or X91(-) variants according to cytochrome b (558) expression. Point mutations in encoding regions represented 50 % of the mutations found in CYBB, splice site mutations 27 %, deletions and insertions 23 %. Eight mutations in CYBB were novel leading to X91(0)CGD cases. Two of these were point mutations: c493G>T and a double mutation c625C>G in exon 6 and c1510C>T in exon 12 leading to a premature stop codon at Gly165 in gp91phox and missense mutations His209Arg/Thr503Ile respectively. Two novel splice mutations in 5'intronic regions of introns 1 and 6 were found. A novel deletion/insertion c1024_1026delCTG/insT results in a frameshift introducing a stop codon at position 346 in gp91phox. The last novel mutation was the insertion of a T at c1373 leading to a frameshift and a premature stop codon at position 484 in gp91phox. For the first time the precise size of two large mutations in CYBB was determined by array-comparative genomic hybridization and carriers' status were evaluated by multiplex ligation-dependent probe amplification assay. No clear correlation between clinical severity and CYBB mutations could be established. Of three mutations in CYBA, NCF1 and NCF2 leading to rare autosomal recessive CGD, one nonsense mutation c29G>A in exon 1 of NCF2 was new.

Human tularemia in France, 2006-2010.

BACKGROUND: Tularemia is an endemic but rare disease in France. We describe the epidemiologic, clinical, diagnostic, treatment, and prognostic aspects of the disease in 101 consecutive patients investigated during a 5-year period (2006-2010). METHODS: All tularemia cases confirmed at the French Reference Center for Tularemia (FRCT) were included. Data were collected both at the Institut de Veille Sanitaire (mandatory notification) and FRCT. Diagnostic methods included serological tests (microagglutination and indirect immunofluorescence assay), Francisella tularensis cultures, real-time polymerase chain reaction (RT-PCR) tests, and molecular identification of the F. tularensis subspecies involved. RESULTS: The patient cohort consisted of 55 men and 46 women (sex ratio, 1.2; average age, 51.7 years), including 93 sporadic cases that occurred throughout France. Contaminations occurred predominantly through contact with or ingestion of lagomorphs (31.7%), tick bites (10.9%), or contaminated environments (7.9%). The glandular and ulceroglandular forms predominated (57.5% of cases), but 18.8% of patients experienced a systemic disease and 29.7% were hospitalized. Specific diagnosis was mainly based on serology, but 38.6% of patients had positive RT-PCR tests and 20.8% had a positive culture. F. tularensis subspecies holarctica was identified in 25 patients. All patients except 1 recovered from infection, but 38.6% experienced relapses despite appropriate antibiotic therapy. CONCLUSIONS: The epidemiological and clinical aspects of tularemia in France are varied, suggesting different modes of contamination. The high rates of systemic diseases and hospitalization indicate that the more serious cases are more likely to be diagnosed and notified. RT-PCR tests may help to improve diagnosis and reporting of the disease.

Effects of age, gender and time on receptor expression and anti-Aspergillus functions of human phagocytes.

Phagocytes play a central role in immune defense. Their dysfunction predisposes to infections. This study determined the expression level of nine receptors involved in Aspergillus immune response as well as the values of phagocytosis and production of radical oxygen species after Aspergillus stimulation, in a healthy adult population. The expression values of the CD11b, CD11c, CD14, CD18, CD35, CD181, CD182, CD282 and CD284 receptors on peripheral human monocytes and granulocytes was established. A heterogenous expression of the CD282 on granulocytes was observed as CD181, CD182 and CD284 on monocytes. Similarly, we observed considerable variation in the expression of these receptors over time. Only CD282 on granulocytes varied with sex. No variation with age was observed. Adherence of Aspergillus conidia to phagocytes was dependent of individual, sex, age and time. A better characterization of these innate immunity parameters is necessary to develop in the future an immunologic surveillance strategy for transplant recipients.

Characteristics and clinical relevance of the quantitative touch-down major surface glycoprotein polymerase chain reaction in the diagnosis of Pneumocystis pneumonia.

The evaluation of quantitative polymerase chain reaction (PCR) characteristics can increase the accuracy of the laboratory diagnosis of Pneumocystis pneumonia (PCP). Between July 2008 and September 2009, 66 non-sequential prospective bronchoalveolar lavage (BAL) samples, obtained from five HIV-infected and 49 non HIV-infected patients were investigated, using a quantitative-touch-down-PCR to determine the number of copies of major surface glycoprotein (MSG) genes of Pneumocystis jirovecii (q-TD-MSG-PCR). PCP was confirmed by microscopic observation of Pneumocystis, radio-clinical and therapeutic data in 18/54 patients. For PCP, the cut-off was 54.3 MSG copies per ml of BAL fluid. The PCR was positive in these same 18 cases and it was the only positive assay in two cases and the earliest diagnosis test in one case of PCP relapse. The likelihood positive ratio, sensitivity and specificity of the q-TD-MSG-PCR were 44, 100% and 97.7%, respectively. The Predictive Negative Value was 100% and the Predictive Positive Value of 95.5%, the intra- and inter-assay variability values were 2.7% (at more than 30 MSG copies) and 11.7% (at 10,000 MSG copies), respectively. Quantitative PCR can help diagnose PCP even in cases of low Pneumocystis load and might decrease morbidity in association with very early specific treatments.

Aspergillus conidia activate the complement by the mannan-binding lectin C2 bypass mechanism.

Innate immunity is the major host defense against invasive aspergillosis. To determine whether the collectin mannan-binding lectin (MBL) is involved in the initial protective immunity through complement activation against opportunistic fungal infections caused by Aspergillus, we performed in vitro studies on 29 different strains of Aspergillus conidia from five different species. Incubation of Aspergillus conidia in human normal serum leads to activation of the alternative pathway, whereas neither the classical nor the lectin pathways through C4 and C2 cleavage are activated. Complement response to conidia was investigated using a MBL-deficient serum and reconstitution experiments were conducted with MBL/MASPs complexes. We found that MBL can directly support C3 activation by a C2 bypass mechanism. Finally, a stronger activation of the alternative pathway was observed for the clinical strains isolated from patients with invasive aspergillosis, compared with the environmental strains.

Diagnosis of toxoplasmosis after allogeneic stem cell transplantation: results of DNA detection and serological techniques.

BACKGROUND: The biological diagnosis of toxoplasmosis after allogeneic hematopoietic stem cell transplantation (HSCT) is based on the detection of Toxoplasma gondii DNA in blood specimens or other samples. Serological testing is used mainly to define the immunity status of the patient before HSCT. The aim of our study was to examine the performance of polymerase chain reaction (PCR) and serological techniques in the diagnosis of toxoplasmosis after HSCT. METHODS: Seventy patients underwent allogeneic HSCT from September 2004 through September 2006. DNA was detected by PCR, and immunoglobulin G and immunoglobulin M were detected by enzyme-linked immunosorbent assay. RESULTS: The results of immunoglobulin G detection before allogeneic HSCT were positive in 40 (57.1%) of the patients and negative in 30 (42.9%). After HSCT, 57 patients (81.4%) had test results that were negative for immunoglobulin M and had negative results of DNA detection, without toxoplasmosis infection. Four patients (5.7%) had at least 4 samples with positive PCR results and/or test results positive for immunoglobulin M against T. gondii; toxoplasmosis was then confirmed by clinical symptoms. Nine patients (12.9%) with positive PCR results and 1 or 2 samples with test results negative for immunoglobulin M were considered to have asymptomatic T. gondii infection. Reactivation of latent infection was the cause of toxoplasmosis in 3 of the 4 patients, and toxoplasmosis occurred as a primary infection in 1 patient. The detection of specific anti-T. gondii immunoglobulin M was the only biological evidence of toxoplasmosis in 2 patients, and samples were positive for immunoglobulin M before PCR was performed in 1 patient. CONCLUSIONS: Thus, after HSCT, all patients were at risk for toxoplasmosis; all patients who receive HSCTs should be followed up with biological testing that combines PCR and serological techniques.

Infective endocarditis-related stroke: diagnostic delay and prognostic factors.

Infective endocarditis is frequently revealed by complications such as stroke, but the diagnostic delay between stroke and infective endocarditis may be long. We retrospectively reviewed all cases of infective endocarditis-associated stroke referred to our institution from 2000 to 2007, with special attention to diagnostic delay and survival. Most (26) of the 34 studied patients presented with stroke before diagnosis of infective endocarditis. The median delay before infective endocarditis diagnosis was 8 d (0-40 d), and was longer in cases with negative blood cultures. Diagnostic delay had no influence upon survival. When diagnosis of infective endocarditis occurred first, stroke developed in 3 patients during the first week of antibiotic therapy; in 3 patients, stroke occurred after valvular surgery. Overall survival was 67.6%; a small vegetation and non-staphylococcal aetiology were associated with a better outcome. In conclusion, infective endocarditis diagnosis is frequently delayed in patients presenting with stroke, particularly if blood cultures are sterile. The risk of delayed stroke after valvular surgery must be considered.

African tick bite fever in elderly patients: 8 cases in French tourists returning from South Africa.

BACKGROUND: African tick-bite fever, a tickborne disease caused by Rickettsia africae, is endemic in rural areas of sub-Saharan Africa and in the French West Indies. Most cases reported in the literature occurred in middle-aged, otherwise-healthy persons and corresponded to benign diseases. The course of African tick bite fever in elderly people is less well documented. METHODS: The medical records of 8 elderly patients infected with R. africae during a trip to South Africa in 2005 are presented to summarize the epidemiologic, clinical, microbiological, treatment, and disease course characteristics. RESULTS: Eight patients, aged 63-75 years, developed African tick bite fever symptoms after a trip to South Africa. R. africae was grown from cutaneous eschar biopsy specimens obtained from 4 patients, confirming African tick bite fever. We observed unusual findings in this elderly population. Rash was frequent (present in 87.5% of patients), vesicular (in 100% of patients with rash), and often associated with an enanthema (in 50% of patients with rash). Severe clinical manifestations occurred: lymphangitis and myocarditis in 1 patient and suspected brain involvement in 2 patients. We observed severe and long-lasting general symptoms, including fever (in 75% of patients), chills (87.5%), asthenia (50%), anorexia (50%), and weight loss (12.5%). With doxycycline therapy, the outcome was favorable in all cases, but complete recovery was slow. CONCLUSION: Ecotourism to sub-Saharan Africa is expanding, and people of advanced age, often with underlying chronic diseases, account for an increasing proportion of travelers. African tick bite fever appears to be more symptomatic in this population. Recommendations advising personal prophylactic measures to prevent tick bites in travelers to regions of endemicity may be particularly important for elderly individuals.

Favorable Evolution of Cryptococcal Meningitis in the Context of Flucytosine Resistance.

Cryptococcal meningitis is a critical illness affecting 0.2% to 5% solid-organ transplant recipients with a 40% to 50% mortality. We report the case of a 48-year-old lung transplant recipient, who, 15 months after a right lung graft, kept parakeets and developed meningitis due to Cryptococcus neoformans. Immunosuppressive treatment was based on a quadruple sequential immunosuppressive therapy that included induction therapy with thymoglobulin, followed by corticosteroids, calcineurin inhibitors, and mycophenolate mofetil. Antifungal susceptibility testing of Cryptococcus neoformans showed resistance to flucytosine and intermediate sensitivity to fluconazole. Initial treatment adhered to international guidelines; however, the patient could not tolerate an effective double-antifungal therapy during the first 2 months of treatment. Despite this delayed treatment for an aggressive infection in an immunocompromised patient, the patient survived without relapse and received maintenance treatment with fluconazole during the course of 3 years. Administration of calcineurin inhibitors as immunosuppressive treatment may partly explain this outcome, as this therapeutic class is known to protect from severe forms of cryptococcal meningitis.

[Cytomegalovirus and cryptogenic inflammatory bowel disease]. / Le cytomégalovirus et les maladies inflammatoires cryptogénétiques de l'intestin.

CMV infection has been reported in association with some flares of IBD. Its prevalence varies with the method of diagnosis and the severity of IBD. Although the link between CMV and IBD is not clear, the immunomodulator properties of the virus may play a role in the evolution of IBD. Besides the necessity of immunosuppression to treat IBD, inflammation per se can maintain in situ viral replication. Antiviral treatment can be useful in some situations. New molecular methods will permit earlier and more sensitive diagnosis of CMV infection and a better evaluation of treatment efficacy.

Acute pseudoseptic arthritis after intraarticular sodium hyaluronan.

A 70-year-old woman with a history of knee osteoarthritis was admitted for acute arthritis 9 days after a second intraarticular injection of sodium hyaluronan (Ostenil). The joint fluid was purulent, with no crystals, and laboratory tests showed marked inflammation, leading to antibiotic treatment for suspected septic arthritis. Incapacitating symptoms persisted, prompting surgical lavage of the knee, which failed to relieve the severe pain. The persistent symptoms and negative results of joint fluid and blood cultures led to discontinuation of the antibiotic therapy after 10 days. Antiinflammatory therapy relieved the symptoms, and the patient was discharged home 1 month after her admission. Nevertheless, the pain persisted, requiring rehabilitation therapy of the knee. Aseptic arthritis induced by repeated sodium hyaluronan injection is the most likely diagnosis. Physicians should be aware of this extremely severe complication.

[Adequacy of antifungal agents in a teaching hospital: too many inappropriate prescriptions despite training]. / Évaluation de la prescription des antifongiques dans un centre hospitalier universitaire : encore trop de prescriptions inadaptées malgré des actions de formation.

OBJECTIVES: The aim of this study was to assess adequacy and conformity of systemic antifungal drugs prescriptions in comparison with local, French, European and international recent guidelines in the Grenoble Teaching Hospital. METHODS: Each prescription of itraconazole, liposomal amphotericin B, voriconazole, caspofungin, micafungin, posaconazole and anidulafungin made between February and October 2010 were reviewed by an infectious diseases specialist. Fluconazole prescriptions' were reviewed only for 15 days. RESULTS: Two hundred and eight patients received 295 systemic antifungal prescriptions. Most of them had at least one risk factor and immunodeficiency was one of the most common. Antifungal treatment starting, molecules choice, administrations conformity (dosage, administration way) were appropriate in 126 cases on 208 (60.5 %) at the treatment beginning evaluation and in 171 cases on 295 (58 %) at the treatment ending evaluation. Antifungal combinations (9.4 %) were less frequent than in the study carried out in Grenoble teaching hospital in 2007 (16.3 %). Most common non-conformities encountered were use of caspofungin instead of fluconazole, antifungal combinations prescription, administration modalities misguiding. The economy that could have been generated by appropriate prescriptions represented 18 % of the antifungal budget of 2010 in the Grenoble Teaching Hospital. CONCLUSION: An improvement was highlighted in the antifungal prescriptions in comparison to the previous study led in 2007 in the Universitary Grenoble Hospital. However, the antifungal use was not optimal and further training is planned.

Optimized Generation of Functional Neutrophils and Macrophages from Patient-Specific Induced Pluripotent Stem Cells: Ex Vivo Models of X(0)-Linked, AR22(0)- and AR47(0)- Chronic Granulomatous Diseases.

Chronic granulomatous disease (CGD) is an inherited orphan disorder caused by mutations in one of the five genes encoding reduced nicotinamide-adenine-dinucleotide-phosphate oxidase subunits, which subsequently lead to impairment in the production of microbicidal reactive oxygen species (ROS). In order to offer several cell line models of CGD and therefore support research on pathophysiology and new therapeutic approaches, we optimized protocols to differentiate induced pluripotent stem cells (iPSCs) from wild-type, X(0)-, AR22(0)- and AR47(0)-CGD patient's fibroblasts into neutrophils and into macrophages. Aberrant genetic clones were discarded after chromosome karyotyping and array-comparative genomic hybridization analysis. All remaining iPSC lines showed human embryonic stem cell-like morphology, expressed all tested pluripotency markers and formed embryoid bodies that contained cells originating from all three primary germ layers. Furthermore, each CGD patient-specific iPSC line retained the gp91 (phox) , p47 (phox) , and p22 (phox) mutations found in the corresponding patient's neutrophils. The average production of CD34(+) progenitors was of 1.5×10(6) cells after 10 days of differentiation of 10×10(6) iPSCs. They were terminally differentiated into about 3×10(5) neutrophils or into 3×10(7) macrophages. Based on morphological, phenotypical, and functional criteria both phagocyte types were mature and indistinguishable from the native human neutrophils and macrophages. However, neutrophils and macrophages derived from X(0)-, AR22(0)-, and AR47(0)-CGD patient-specific iPSC lines lacked ROS production and the corresponding mutated proteins. To simplify the phagocytes' production upon request, progenitors can be cryopreserved. In conclusion, we describe a reproducible, simple, and efficient way to generate neutrophils and macrophages from iPSCs and provide a new cellular model for the AR22(0)-CGD genetic form that has not been described before.