A case report of Guillain Barré syndrome revealing underlying infective endocarditis due to Cardiobacterium hominis.

RATIONALE: Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy presumed to result from an infection-triggered autoimmune reaction. PATIENT CONCERNS: This paper describes a 53-year-old man admitted to hospital for deterioration of his general condition. DIAGNOSIS: He developed GBS, confirmed by lumbar puncture and electromyogram, which recovered after intravenous immunoglobulins. A grade 2 aortic regurgitation was detected by transthoracic echocardiography upon diagnosis of GBS, but in the absence of fever, no further investigations were conducted. A few weeks later, the patient presented with fever and infective endocarditis (IE) was diagnosed after the identification of vegetation on the aortic valve with transesophageal echocardiography. The etiologic agent was identified as Cardiobacterium hominis based on 3 positive blood cultures and DNA detection in valvular material. INTERVENTIONS: IE was cured with a 6-week course of antibiotics and aortic valve replacement. OUTCOMES: The patient completely recovered from Guillain-Baré syndrome and IE. LESSONS: This case of GBS associated with C hominis endocarditis, emphasizes the importance of blood cultures and transesophageal echocardiography for the detection of IE and highlights the insidious nature of C hominis endocarditis which is often diagnosed late.

Tolerability of postexposure prophylaxis with the combination of zidovudine-lamivudine and lopinavir-ritonavir for HIV infection.

Tolerability of the combination of zidovudine-lamivudine and lopinavir-ritonavir as postexposure prophylaxis (PEP) for human immunodeficiency virus infection was prospectively assessed. A total of 121 patients were enrolled in the study; 23 patients discontinued PEP prematurely for reasons other than adverse events. Of the other 98 patients, 58 (59%) experienced adverse effects, which led to premature PEP discontinuation in 20 cases (20%).

In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8-year period.

Infective endocarditis (IE) remains severe. Few predictors of prognosis have been identified. It is not known whether mortality of IE has decreased during recent decades. 559 definite cases of IE were collected in a prospective population-based survey in 1999 in France. In-hospital death rate was 17%. It was lower in operated patients (14.4% vs 19.3%), although not significantly so. In multivariate analysis, the following variables were independent and significant predictors of mortality: history of heart failure (odds ratio: 2.65), history of immunosuppression (OR: 3.34), insulin-requiring diabetes mellitus (OR: 7.82), left-sided IE (OR: 1.97), heart failure (OR: 2.19), septic shock (OR: 4.33), lower Glasgow coma scale score (OR: 4.09), cerebral haemorrhage (OR: 9.46), and higher C-reactive protein level (OR: 2.60). Adjusted mortality was significantly lower in 1999 than in 1991 (22%): OR: 0.64 (p = 0.03). Thus, in a large and unselected cohort of patients hospitalized for IE in 1999, in-hospital mortality rate was lower than in 1991. Multivariate analysis identified factors classically known as having an impact on mortality. However, other factors, such as age and responsibility of Staphylococcus aureus, were not retained in the model.

High seroprevalence of herpes simplex virus type 2 infection in French human immunodeficiency virus type 1-infected outpatients.

Using commercially available herpes simplex virus (HSV) type-specific serological diagnostic tests, HSV type 2 (HSV-2) antibody prevalence was assessed in two parallel prospective studies including 534 human immunodeficiency virus type 1 (HIV-1)-infected outpatients living in two areas of northern France. In the first cohort of 434 subjects, 223 (51%) individuals demonstrated a positive HSV-2 serological status while 66 (66%) of 100 subjects in the second cohort were seropositive for HSV-2 (51 versus 66%; P = 0.08). Among the 223 HSV-2-seropositive subjects identified in the first study cohort, only 22 (10%) had suffered from recurrent anogenital lesions during the past 12 months while 154 (69%) had no clinical history of herpesvirus infection. Our findings demonstrate high proportions of subclinical and undiagnosed HSV-2 infection in HIV-1-infected individuals and suggest that HSV type-specific serological testing in the French HIV-1-infected subpopulation could be an efficient strategy to diagnose clinically asymptomatic HSV-2 infections.

Osteonecrosis in six HIV-infected patients receiving highly active antiretroviral therapy.

OBJECTIVE: To report 6 cases of osteonecrosis in HIV-infected patients treated with highly active antiretroviral therapy (HAART) and compare the observed risk factors with those of published cases. CASE SUMMARIES: Osteonecrosis was diagnosed between 1999 and 2002 in 6 of 417 HIV-infected patients in our department of infectious diseases. At the time of diagnosis, mean patient age was 42 years, and 5 patients had developed AIDS. Mean CD4+ lymphocyte count was 563.5 cells/mm(3) and viral load was undetectable (<50 copies/mL) in 5 patients. The patients' mean body mass index was 22.5 kg/m(2). Four had lipodystrophy. All were receiving HAART, including a protease inhibitor in 4 patients; the remaining 2 patients had a history of protease inhibitor treatment. Median time from the first antiretroviral therapy to osteonecrosis diagnosis was 46.5 months. Established risk factors were the use of corticosteroids in 2 patients and dyslipidemia in all patients. All of the patients developed pain and functional impotence of the hip or ankle joints. Osteonecrosis of the hip was bilateral in 4 cases. Three patients required surgical intervention, all of whom had favorable outcomes. DISCUSSION: HIV-infected patients are at a higher risk for the development of osteonecrosis and are more likely to be exposed to predisposing factors to its development. The HAART implication as a predisposing factor remains controversial. CONCLUSIONS: The pathogenesis of osteonecrosis in HIV-infected individuals may be multifactorial; the reasonable approach for clinicians consists of treating concomitant predisposing conditions that might further cause osteonecrosis.

[Diagnostic value of clinical signs in giant cell arteritis: analysis of 415 temporal artery biopsy findings]. / Valeur diagnostique des signes de la maladie de Horton.

AIM OF THE STUDY: The American College of Rheumatology (ACR) has proposed a list of criteria for diagnosis of giant cell arteritis in order to guide clinical research by differentiating it from other vasculitis. The aim of this retrospective investigation, based on the findings of 415 temporal artery biopsies was to assess the diagnostic value of these criteria in the daily clinical setting. METHODS: The demographic, clinical and biological characteristics of patients with positive (confirmed cases of giant cell arteritis) or negative (controls) histopathological temporal artery biopsy findings were analyzed using downward step-by-step logistic regression analysis. This analysis enabled investigators to list signs with inherent diagnostic value. Based their odds-ratio, these factors were used to determine a clinical score for giant cell arteritis. RESULTS: A score of over 7 - out of a maximum score of 32 - enables the diagnosis for giant cell arteritis with the best possible compromise between a sensitivity of 75.7% and a specificity of 72.2%. ACR criteria had a sensitivity of 97.5% and a specificity of 78.9% when used in our patient group. CONCLUSION: Our study results are original in that the control group was composed of patients in whom the diagnosis of giant cell arteritis had been suggested but refuted by the absence of histopathological findings on the temporal artery biopsy. This pragmatic attitude in selecting the control group may explain the difference observed with the ACR criteria in terms of sensitivity and specificity. Further research is needed to develop a diagnostic method for giant cell arteritis without resorting to temporal artery biopsy.

Changing profile of infective endocarditis: results of a 1-year survey in France.

CONTEXT: Since the first modern clinical description of infective endocarditis (IE) at the end of the 19th century, the profile of the disease has evolved continuously, as highlighted in epidemiological studies including a French survey performed in 1991. OBJECTIVE: To update information gained from the 1991 study on the epidemiology of IE in France. DESIGN AND SETTING: Population-based survey conducted from January through December 1999 in all hospitals in 6 French regions representing 26% of the population (16 million inhabitants). PATIENTS: Three hundred ninety adult inpatients diagnosed with IE according to Duke criteria. MAIN OUTCOME MEASURES: Incidence of IE; proportion of patients with underlying heart disease; clinical characteristics; causative microorganisms; surgical and mortality outcomes. RESULTS: The annual age- and sex-standardized incidence was 31 (95% confidence interval [CI], 28-35) cases per million, not including the region of New Caledonia, which had 161 (95% CI, 117-216) cases per million. There was no previously known heart disease in 47% of the cases. The proportion of prosthetic-valve IE was 16%. Causative microorganisms were: streptococci, 48% (group D streptococci, 25%; oral streptococci, 17%, pyogenic streptococci, 6%); enterococci, 8%; Abiotrophia species, 2%; staphylococci, 29%; and other or multiple pathogens, 8%. Blood cultures were negative in 9% and no microorganism was identified in 5% of the cases. Early valve surgery was performed in 49% of the patients. In-hospital mortality was 16%. Compared with 1991, this study showed a decreased incidence of IE in patients with previously known underlying heart disease (20.6 cases per million vs 15.1 cases per million; P<.001); a smaller incidence of oral streptococcal IE (7.8 cases per million vs 5.1 cases per million; P<.001), compensated by a larger proportion of IE due to group D streptococci (5.3 cases per million vs 6.2 cases per million; P =.67) and staphylococci (4.9 cases per million vs 5.7 cases per million; P =.97); an increased rate of early valve surgery (31.2% vs 49.7%; P<.001); and a decreased in-hospital mortality rate (21.6% vs 16.6%; P =.08). CONCLUSION: Although the incidence of IE has not changed, important changes in disease characteristics, treatment, and outcomes were noted.