An estimation of burden of serious fungal infections in France.

OBJECTIVE OF THE STUDY: An estimation of burden of serious fungal diseases in France is essential data to inform public health priorities on the importance of resources and research needed on these infections. In France, precise data are available for invasive fungal diseases but estimates for several other diseases such as chronic and immunoallergic diseases are by contrast less known. MATERIALS AND METHODS: A systematic literature search was conducted using the Web of Science Platform. Published epidemiology papers reporting fungal infection rates from France were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in those populations to estimate national incidence or prevalence, depending on the condition. RESULTS: The model predicts high prevalences of severe asthma with fungal sensitization episodes (189 cases/100,000 adults per year), of allergic bronchopulmonary aspergillosis (145/100,000) and of chronic pulmonary aspergillosis (5.24/100,000). Besides, estimated incidence for invasive aspergillosis is 1.8/100,000 annually based on classical high risk factors. Estimates for invasive mucormycosis, pneumocystosis and cryptococcosis are 0.12/100,000, 1/100,000 and 0.2/100,000, respectively. Regarding invasive candidiasis, more than 10,000 cases per year are estimated, and a much higher number of recurrent vaginal candidiasis is probable but must be confirmed. Finally, this survey was an opportunity to report a first picture of the frequency of tinea capitis in France. CONCLUSION: Using local and literature data of the incidence or prevalence of fungal infections, approximately 1,000,000 (1.47%) people in France are estimated to suffer from serious fungal infections each year.

[Gastrointestinal parasitic carriage in adopted children]. / Portage parasitaire digestif d'enfants adoptés.

INTRODUCTION: Intestinal parasitoses are very common infections in tropical areas. By contrast, they are rarely diagnosed in developed countries, and are mostly seen in specific populations. PATIENTS AND METHODS: This analytical observational study was longitudinally performed in a French university hospital (2007-2011). It dealt with the study of gastrointestinal carriage of parasites in internationally adopted children. A standard stool examination was therefore systematically undertaken for every new immigrant. Association with risk factors was made by uni- and multivariate analysis. RESULTS: Overall, 69 stool samples were analyzed. The proportion of positive samples was 78 %. Protozoans, mainly Giardia duodenalis, were more prevalent than helminths. In univariate analysis, a subject's low weight and height were significantly associated with intestinal parasite carriage. Amoebae were more frequent in older children and in children from Haiti, as confirmed by the trend observed in the multivariate analysis. Flagellates were seen more often in African children. Infections with multiple parasite species were observed in half of the study population, and were inversely correlated to increasing age. DISCUSSION: According to the results of this study, gastrointestinal parasites are still very frequent in stool samples from immigrant children. Since they are easy to transmit, the majority of infections were protozoan. The best antiparasitic strategy lies in: (a) the routine screening of stool from any immigrant child coming from endemic areas and (b) the use of antiparasitic treatment.

Multicenter Comparison of the Etest and EUCAST Methods for Antifungal Susceptibility Testing of Candida Isolates to Micafungin.

In vitro susceptibility of 933 Candida isolates, from 16 French hospitals, to micafungin was determined using the Etest in each center. All isolates were then sent to a single center for determination of MICs by the EUCAST reference method. Overall essential agreement between the two tests was 98.5% at ±2 log2 dilutions and 90.2% at ±1 log2 dilutions. Categorical agreement was 98.2%. The Etest is a valuable alternative to EUCAST for the routine determination of micafungin MICs in medical mycology laboratories.

Insecticide resistance in Anopheles mosquitoes : additional obstacles in the battle against malaria.

Mosquitoes of the genus Anopheles are malaria vectors in tropical areas and were of course designated as primary targets by programs for malaria control. Repellent sprays, indoor use of insecticides, and massive delivery of mosquito nets are standard examples of the means widely used to combat malaria. This synthetic review supplies an overview of all of the modes of resistance developed by Anopheles mosquitoes against these human actions. The misuse of each available tool has gradually led to a decrease in its global effectiveness. Newly-emerging forms of resistance, due to modification or overexpression of molecular targets, as well as behavioral adaptations by mosquitoes, are some examples of the consequences. To enable a categorical reduction in malaria incidence, a thorough adjustment of the use of the various means of control should be envisioned.

Impact of advice given to travelers concerning the main infectious risks associated with traveling in the tropics.

INTRODUCTION: The prevention of sanitary risks related to traveling in the tropics implies delivering a large amount of information to travelers. The objective of our study was to assess the knowledge acquired by travelers during a pre-travel consultation. METHODS: A before and after study was conducted among 202 travelers having consulted at the Tours international vaccine center. We used self-administrated questionnaires (score out of 100 marks) concerning diet, hygiene, anti-vectorial prevention (AVP), and sexual-transmitted infections (STI). The scores obtained before and after consultation were compared globally and for each topic. RESULTS: The travelers' global knowledge had improved after consultation (66.1 vs. 75.5%; P < 0.0001) as well as for each topic. The most important improvement concerned hygiene (+12.5%; P < 0.0001) and the lowest concerned STI (+5.8%; P < 0.0001). The multivariate analysis revealed that not having searched for information before consulting was the main factor associated with global knowledge improvement (P < 0.0001) (unplanned professional traveling compared to humanitarian mission prepared ahead of departure time). The recommendations for diet were less well acquired in travelers > 50 years of age than in those < 30 years of age (P < 0.002). CONCLUSION: A specialized pre-travel consultation improves the travelers' knowledge for the main prevention measures but does not allow them to acquire all required knowledge. Taking into account the travelers' initial knowledge and their ability to learn could improve the impact of the pre-travel consultation.

[Bacterial flora in blepharitis]. / La flore bactérienne dans les blépharites.

INTRODUCTION: Blepharitis has multiple, poorly defined origins. The goal of this study was to investigate the bacterial flora present in patients affected with blepharitis in comparison with healthy subjects, so as to understand the role of bacterial etiologies in blepharitis. MATERIALS AND METHODS: Fifty-four patients with blepharitis and 50 healthy controls participated in this study. Swabs were obtained and analyzed qualitatively and quantitatively for bacteria. A subgroup of 16 people (9 with blepharitis and 7 controls) also were investigated for Demodex. RESULTS: The percentages of the positive cultures and the number of colonies/case were clearly higher for patients with blepharitis in comparison with healthy controls. Bacteria were isolated for 81% of cases versus 38% for controls, with a mean of 39 colonies versus 4.4 colonies for controls. Corynebacterium sp. were the most common microorganisms isolated from patients with blepharitis (53.7% for cases versus 18% for controls, P<0.01), and the bacterial load was 15 times higher (37.4 col/case versus 2.6 col/case). C. macginleyi was the most common Corynebacteria (33% versus 6%, P<0.01). S. epidermidis: 35.1% versus 16% (P=0.02) with 11.3 col/case versus 1.6 col/case. S. aureus: 13% versus 0% (P=0.01) with 24.7 col/case versus 0. We did not find a significant difference for Propionibacterium acnes: 14.8% versus 14% with 4.7 col/case versus 5.1 col/case, or for Demodex, with 22.2% versus 28.6%. CONCLUSION: Corynebacterium sp. and especially C. macginleyi seem to participate actively in the physiopathology of blepharitis. S. epidermidis and S. aureus also remain associated with this pathology.

[Epidemiological transition of mycosis diseases in sub-Saharan Africa: from surface to depth]. / La transition épidémiologique des mycoses en Afrique subsaharienne : de la surface vers la profondeur.

Fungi are schematically responsible for three distinct kinds of infections: superficial mycoses, subcutaneous and deep ones. The current socio-epidemiological transition observed in sub-Saharan Africa does not actually lead to similar consequences regarding these three categories of fungal entities. For instance, it has long been known that superficial mycoses are very prevalent in tropical areas, since they are partly due to the warm climate and the promiscuity. They are mostly caused by dermatophytic fungi or Malassezia sp. (Pityriasis versicolor). Subcutaneous mycoses are rarer, and usually due to dimorphic fungi which are accidentally inoculated into the body after a skin injury or a trauma. Sometimes very spectacular, the clinical outcome is then described as chronic. Thus, chromoblastomycosis, rhinoentomophtoromycosis or mycetoma are some examples of subcutaneous mycoses which remain well-known by practitioners of endemic countries. Deep mycoses (or invasive / systemic mycoses) are defined by fungal infections of deep anatomical sites that should be normally sterile. By contrast with the other entities mentioned above, the outcome may be rapidly fatal for the patient. One of the most outstanding examples was the great increasing of cryptococcal meningitis during the HIV outbreak in the 80'. A few other similar mycoses may be feared in a near future, since they usually occur in contexts of important immunosuppression which are about to be definitely experienced in Africa: overall increase of chronic diseases like diabetes, lengthening life expectancy and its associated diseases, widespread medical practices which were only seen in advanced intensive care units, onco-haematology departments or graft centers so far. Thus, the deep mycoses will inevitably increase in Africa, as they did in all developed countries over the last two decades. The consequences will not only be limited to the clinical management as described above: the diagnostic approach is also quite particular, since the identification of the involved fungal species should be established in emergency, if not the outcome will be fatal. Besides, the antifungal drugs are expensive, and their therapeutic monitoring is quite challenging all along the follow up. Overall, we have to thoroughly take into account the emergence of invasive mycoses right now in Intertropical Africa, in order to successfully achieve the socio-economic development of this continent.

[Cutaneous mucormycosis caused by Rhizopus microsporus]. / Mucormycose cutanée à Rhizopus microsporus.

BACKGROUND: Mucormycosis are rare fungal infections occurring chiefly in the lung or the rhinocerebral compartment, particularly in patients with immunodeficiency or mellitus diabetes. We report the case of an elderly patient with cutaneous mucormycosis caused by Rhizopus microsporus. PATIENTS AND METHODS: An 89-year-old man presented a skin lesion of the forearm rapidly becoming inflammatory and necrotic. The patient had been treated for 2months with oral corticosteroids for idiopathic thrombocytopenia. Histological and mycological examination of the skin biopsy revealed the presence of a filamentous fungus, R. microsporus. The outcome was unfavorable, despite prescription of high-dose liposomal amphotericin B. DISCUSSION: Mucormycosis are infrequent opportunistic infections caused by angio-invasive fungi belonging to the Mucorales order. Cutaneous presentations are rare, and in rare cases the species R. microsporus is isolated in clinical samples. Diagnosis is based on histological examination highlighting the characteristic mycelium within infected tissue, together with ex vivo mycological identification using morphological and molecular methods. Treatment consists of liposomal amphotericin B combined with debridement surgery. CONCLUSION: R. microsporus is a marginal fungal species rarely isolated in clinical practice, and even less in dermatology departments. This clinical case report highlights the severity of infection with this fungus, particularly in the absence of early surgery.

Diagnosis of invasive pulmonary aspergillosis: updates and recommendations.

Invasive pulmonary aspergillosis is an opportunistic mycosis, difficult to diagnose, due to the environmental fungi of the genus Aspergillus. The diagnostic tools, even if more are available, are still limited in number and effectiveness. The current recommendations issued by the EORTC/MSG (European Organization of Research and Treatment of Cancer/Mycoses Study Group) and the ECIL (European Conference for Infection in Leukemia) suggest collecting epidemiological, radio-clinical, and biological data to support the diagnosis of aspergillosis with a strong presumption. Thus, medical imaging and serum galactomannan antigen currently constitute the basis of the screening approach, although they both have some limitations in specificity. (1→3)-ß-D-glucans are pan-fungal serum markers with a very good negative predictive value. Real-time PCR lacks standardization, and fungal culture from respiratory specimens is sometimes not sensitive enough. Histology allows proving the diagnosis of aspergillosis, but biopsy is not always possible in immunodepressed patients. We present the various arguments for the diagnosis of invasive aspergillosis, with a particular emphasis on recent exploration techniques.

Evaluation of two matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) systems for the identification of Candida species.

Candida spp. are responsible for severe infections in immunocompromised patients and those undergoing invasive procedures. The accurate identification of Candida species is important because emerging species can be associated with various antifungal susceptibility spectra. Conventional methods have been developed to identify the most common pathogens, but have often failed to identify uncommon species. Several studies have reported the efficiency of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for the identification of clinically relevant Candida species. In this study, we evaluated two commercially available MALDI-TOF systems, Andromas™ and Bruker Biotyper™, for Candida identification in routine diagnosis. For this purpose, we investigated 1383 Candida isolates prospectively collected in eight hospital laboratories during routine practice. MALDI-TOF MS results were compared with those obtained using conventional phenotypic methods. Analysis of rDNA gene sequences with internal transcribed regions or D1-D2 regions is considered the reference standard for identification. Both MALDI-TOF MS systems could accurately identify 98.3% of the isolates at the species level (1359/1383 for Andromas™; 1360/1383 for Bruker Biotyper™) vs. 96.5% for conventional techniques. Furthermore, whereas conventional methods failed to identify rare or emerging species, these were correctly identified by MALDI-TOF MS. Both MALDI-TOF MS systems are accurate and cost-effective alternatives to conventional methods for mycological identification of clinically relevant Candida species and should improve the diagnosis of fungal infections as well as patient management.

The Mobile Team of Parasitology-Mycology, a medical entity for educational purposes to serve sick patients.

The Mobile Team of Parasitology-Mycology is a movable entity of the Parasitology-Mycology laboratory of Tours University Hospital, France. In contrast to the usual prerogatives of biomedical laboratories, the Mobile Team of Parasitology-Mycology is requested to intervene directly at bedside in various clinical departments, or even outside the hospital facility. Although its actions are of course primarily devoted to specialized diagnostic and therapeutic purposes, the Mobile Team also plays an important educational role in the medical training of undergraduate or graduate students.

Successful treatment with fumagillin of the first pediatric case of digestive microsporidiosis in a liver-kidney transplant.

We report the first successful use, to our knowledge, of fumagillin alone in a pediatric patient to cure intestinal microsporidiosis in a liver-kidney transplanted child. Detection of Enterocytozoon bieneusi in stool became negative from the first post-therapeutic control, while digestive symptoms disappeared in 4 days. During a 9-month follow-up, polymerase chain reaction and direct examinations remained negative for microsporidia in her feces. No major undesirable effects were noted during the anti-microsporidial therapy.

[Non-antibiotic anti-infectious treatments in urology]. / Les médicaments anti-infectieux non antibiotiques en urologie.

OBJECTIVE: To define the terms of use of pesticides, antifungal, antiviral and antiseptic treatments in urology. MATERIALS AND METHODS: A literature search was conducted on MEDLINE for all these treatments used in urology. The molecules were classified by family. Modes of action, indications in urology and adverse effects have been detailed. Authorisation files were consulted and then complemented by a literature analysis. RESULTS: Although parasitic or viral diseases are uncommon in urology, their specific treatment deserves a thorough knowledge of pesticide and antiviral molecules. Antifungal treatments are regularly used in urology with special features to know to improve the efficacy/safety ratio. Antiseptics are used daily in urology and a better understanding of these molecules allows better use. CONCLUSION: Beyond antibiotics, antiviral, antiparasitic and antifungal deserve a thorough knowledge. Antiseptic although used daily have features little known.

Sudden death due to cerebral malaria: a case report.

Malaria is generally diagnosed ante-mortem. Few post-mortem cases have been described in the literature. Post-mortem cases may present as sudden and unexpected deaths of young individuals rising suspicious of unnatural death, and may therefore be investigated by medical examiners. We present the case of a 24-year-old man who died a few days after returning from a trip to Mali (Africa). Death was attributed to cerebral malaria after a thorough post-mortem investigation. The pathological aspects underlying the fatal outcome are discussed.

Eumycetoma of the foot caused by Exophiala jeanselmei in a Guinean woman.

Eumycetomas are chronic infectious entities characterized by presence of mycotic grains in (sub-)cutaneous tissues, after accidental inoculation of an exogenous filamentous fungus in the skin. The lesions evolve towards painless pseudotumor of the soft parts. We report the original case of a Guinean woman exhibiting eumycetoma of the right foot. Both laboratory tests identified a dematiaceous fungus, Exophiala jeanselmei, as the responsible infectious agent. A medical treatment with voriconazole alone was sufficient to notice a substantial clinical improvement. This finding is unusual as E. jeanselmei is uncommon in Guinea-Conakry, and as optimal treatment rather associate antifungal azoles and surgical excision.

Usefulness of corticosteroid therapy during chronic disseminated candidiasis: case reports and literature review.

OBJECTIVES: Chronic disseminated candidiasis (CDC) is a disseminated fungal infection that is frequently seen in patients undergoing intensive treatment of haematological malignancies. The first signs of CDC appear during neutrophil recovery. Clinical and physiopathological characteristics of CDC suggest it belongs to the spectrum of fungus-related immune reconstitution inflammatory syndrome (IRIS). We report five cases of CDC treated with antifungal therapy and adjuvant corticosteroids to decrease the exacerbated inflammatory response. METHODS: We conducted a retrospective study in the Haematology Department of the University Hospital of Tours, France. The five reported cases were treated for CDC with antifungal therapy and adjuvant corticosteroids. RESULTS: Of the five cases of CDC, one was proven and four were possible, according to the 2008 European Organization for Research and Treatment of Cancer (EORTC) classification. All patients were being treated for acute leukaemia. In all cases, symptoms disappeared 2.8 days (range, 1-7) after the beginning of adjunctive corticosteroid therapy. Corticosteroids were administered on average for 146 days (range, 4 weeks-1 year) and antifungal therapy was administered for the duration of chemotherapy consolidation. There was no exacerbation of CDC symptoms during the next round of chemotherapy or bone marrow transplantation. One patient died from relapse of leukaemia. CONCLUSIONS: Within the framework of IRIS, adjuvant corticosteroid therapy could rapidly improve CDC symptoms and allow continued chemotherapy without delay and without compromising the haematological prognosis.

Evaluation of a rapid enzyme-linked immunosorbent assay for diagnosis of strongyloidiasis.

Diagnosis of strongyloidiasis using stool examination remains unsatisfactory due to the lack of sensitivity and fastidious techniques. In this work, we investigated the value of an anti-Strongyloides IgG enzyme immunoassay (EIA), using a panel of 207 sera retrospectively collected from patients with definitive diagnoses of strongyloidiasis (n=57), other helminthic infections (n=46), eosinophilia without parasitic infection diagnosis (n=54), and digestive disturbances following a tropical journey (n=30) and from 20 negative controls. By following a receiver operating characteristic (ROC) curve analysis, it was possible to optimize the test to reach a sensitivity of 91.2% and a specificity of 93.3%, with 92.8% of patients correctly classified. Considering the incidence of strongyloidiasis diagnosed in our own laboratory, the negative predictive value was calculated at 99.9%. In conclusion, this test is very rapid and easy to perform and may be valuable for diagnosis of strongyloidiasis both in cases where the infection is unrevealed by a parasitological stool examination and in patients at risk for severe clinical forms, such as patients receiving immunosuppressive therapy.