Pregnancy outcomes in women with imported malaria in mainland France: A retrospective study from 2004 to 2014.

OBJECTIVES: There is little data on pregnant women with imported malaria in high-income countries, especially regarding offspring outcomes. We wanted to determine pregnancy outcomes of imported malaria in pregnant women in mainland France. PATIENTS AND METHODS: We conducted a retrospective, descriptive study of outcomes in pregnant women hospitalized with malaria from 2004 to 2014 in two regions of mainland France. An adverse outcome was defined as a miscarriage, stillbirth, preterm birth (<35 weeks of gestation), low birth weight (LBW) defined as less than 2500 g, or congenital malaria. RESULTS: Of 60 pregnancies, 5 were excluded because of elective abortions; 55 were investigated, of which 11 were primigravidae and 44 multigravidae. Pregnancies were singleton (n = 51) or twin (n = 4). Mean age was 30.4 years (range:19-45 y). Among the 55 cases, 9 ended in a miscarriage (8 singletons and 1 twin pregnancy) and 1 had a stillbirth at 21 weeks of gestation, all immediately after the malarial episode. 45 gave birth (29 vaginal deliveries and 16 caesarean sections) to 48 (42 singletons and 6 twins) newborns. Amongst these, 30 were healthy full-term newborns, 10 had LBW, and 8 were preterm. Overall, 26 of 55 (47.3%) pregnancies, and 29 of 59 (49.2%) offsprings had adverse outcomes. Compared to singleton pregnancies, twin pregnancies were associated with adverse outcomes (p = 0.0438). CONCLUSIONS: Imported malaria has a severe impact on pregnancy outcomes. Prevention and management of imported malaria in pregnancy should be optimized.

How do we fight COVID-19? Military medical actions in the war against the COVID-19 pandemic in France.

'We are at war', French President Emmanuel Macron said in an address to the nation on 16 March 2020. As part of this national effort, the French Military Medical Service (FMMS) is committed to the fight against COVID-19. This original report aimed to describe and detail actions that the FMMS has carried out in the nationwide fight against the COVID-19 pandemic in France, as well as overseas. Experts in the field reported major actions conducted by the FMMS during the COVID-19 pandemic in France. In just few weeks, the FMMS developed ad hoc medical capabilities to support national health authorities. It additionally developed adaptive, collective en route care via aeromedical and naval units and deployed a military intensive care field hospital. A COVID-19 crisis cell coordinated the French Armed Forces health management. The French Military Centre for Epidemiology and Public Health provided all information needed to guide the decision-making process. Medical centres of the French Armed Forces organised the primary care for military patients, with the widespread use of telemedicine. The Paris Fire Brigade and the Marseille Navy Fire Battalion emergency departments ensured prehospital management of patients with COVID-19. The eight French military training hospitals cooperated with civilian regional health agencies. The French military medical supply chain supported all military medical treatment facilities in France as well as overseas, coping with a growing shortage of medical equipment. The French Armed Forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the review of the scientific literature on COVID-19 daily and provided expert recommendations on biosafety. Finally, even students of the French military medical academy volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the FMMS engaged multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. The collaboration between military and civilian healthcare systems reinforced the shared objective to achieve the goal of 'saving the greatest number'.

Community-acquired pneumonia in the emergency department: an algorithm to facilitate diagnosis and guide chest CT scan indication.

OBJECTIVE: The aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED). METHODS: We performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion. RESULTS: Among the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66-80), specificity 89% (95% CI 83-94), positive predictive value (PPV) 88% (95% CI 81-93), negative predictive value (NPV) 76% (95% CI 69-82) and area under the curve (AUC) 0.81 (95% CI 0.77-0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81-92), specificity 72% (95% CI 60-81), PPV 86% (95% CI 79-91), NPV 75% (95% CI 63-84) and AUC 0.80 (95% CI 0.73-0.87). CONCLUSION: Our CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.

Hypereosinophilia and epigastralgia after visiting Tunisia: a rare differential diagnosis of helminthiases.

Causes of hypereosinophilia among travelers returning from North Africa are dominated by helminth infections, especially when associated with gastrointestinal signs. Non-infectious causes must nonetheless be investigated after negative microbiological assessment and failure of a broad empiric antiparasite treatment. We report the case of a young man with epigastralgia and major weight loss since a stay in Tunisia. Empiric treatment with albendazole was not successful. Eosinophilic gastroenteritis was diagnosed and resolved under corticosteroid treatment.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury.

BACKGROUND: This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS: Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS: A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS: Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

[Disseminated nocardiosis caused by Nocardia nova with brain abscesses and osteomyelitis in an immunocompetent patient]. / Nocardiose disséminée à Nocardia nova avec abcès cérébraux et ostéomyélite chez un patient immunocompétent.

INTRODUCTION: Nocardia is an opportunist bacteria involved in patients with cellular immunodepression or chronic lung disease. The most frequent portals of entry are the respiratory tract by inhalation or direct inoculation through a cutaneous effraction. Nocardiosis may be localised or disseminated. CASE REPORT: We report a rare case of disseminated nocardiosis to Nocardia nova with pulmonary, cutaneous, cerebral attacks and femoral osteomyelitis. The diagnosis was confirmed by prolonged cultures of the bronchoalveolar fluid and the pus extracted from a cutaneous lesion. The outcome was favorable under adapted and prolonged antibiotherapy with imipenem and amikacine and then cotrimoxazole. CONCLUSION: This observation is original because it involves a immunocompetent patient with an association of two exceptional locations for N. nova: brain abscesses and femoral osteomyelitis. Screening for cerebral involvement should be systematic, even in the lack of neurological signs. An adapted and prolonged antibiotherapy must be conducted.

Severe infectious mononucleosis in immunocompetent adults.

OBJECTIVES: To determine the risk factors for severe infectious mononucleosis (IM) occurrence in immunocompetent adults. METHODS: We performed a multicenter, retrospective case series including immunocompetent adults presenting with confirmed IM between 2001 and 2011. Severe presentations were compared with uncomplicated presentations using Stata® 9 software. The significance level was set at 5%. RESULTS: In univariate analysis, age over 30 years (n=13 or 41.9% vs. n=5 or 12.8%; P=0.006), prior use of non-steroidal anti-inflammatory drugs (NSAIDs) (n=7 or 87.5% vs. n=1 or 12.5%; P=0.009), and smoking (n=13 or 68.4% vs. n=6 or 31.6%; P=0.013) were associated with severe IM onset. In multivariate analysis, only age over 30 years (OR=3.55; P=0.05) and prior use of NSAIDs (OR=15; P=0.05) remained associated with severe IM onset, without reaching significance level (P=0.05). CONCLUSION: Our study confirmed that age over 30 years is a risk factor for severe IM onset. Prior use of NSAIDs also seems to be correlated with severe presentations. This new data needs to be confirmed in a prospective study.

[Ebola virus disease: Clinical presentation, prognosis and treatment]. / Maladie à virus Ebola : présentation clinique, aspects pronostiques et principes thérapeutiques.

The clinical spectrum of Ebola virus disease (EVD) ranges from very serious forms with organ failure and death within days to paucisymptomatic forms and perhaps even asymptomatic. The authors propose a focus on the clinical manifestations of EVD, on prognosis and on therapeutic aspects (excluding resuscitation). This work extracts from the literature the main data gathered during the 2014-2015 epidemic that raged in Guinea Conakry and Sierra Leone. These two countries, even if they are separated by a border, are one and the same population base. The characteristics of the epidemic in Liberia have not been analyzed. The authors have treated EVD patients in the health workers treatment center of Conakry and enrich this work about their personal experience.

[Bloodstream infection due to Campylobacter fetus subspecies fetus and skin involvement: A case series of three patients]. / Bactériémie à Campylobacter fetus subspecies fetus et manifestations cutanées : à propos de trois cas.

INTRODUCTION: Among the species of Campylobacter, C. fetus subspecies fetus is characterized by extra-intestinal manifestations, including bloodstream and cardiovascular infections, occurring preferentially in the context of immunosuppression. The cutaneous lesions are rarely described but may be underestimated. CASE REPORTS: We report on 3 cases of cellulitis with bloodstream infection due to Campylobacter fetus subspecies fetus, without cardiovascular infection in a 72- and 85-year-old women, respectively, and a 79-year-old man. Outcome was successful in all 3 cases after prolonged amoxicillin-clavulanic acid treatment, without relapse. CONCLUSION: C. fetus subspecies fetus is rarely associated with skin and soft tissue infections. Cardiovascular complications may be searched in such context.

[Acute pericarditis and tamponade: An unusual revelation of a visceral tuberculosis]. / Péricardite aiguë et prétamponnade: un mode de révélation atypique d'une tuberculose viscérale.

Tuberculosis is a common pulmonary disease, which is still endemic in disadvantaged communities. Pericarditis is a rare but very lethal visceral localization. The authors report the case of a 58-year-old man, without neither medical history nor social risk, who presented a cardiac tamponade as the first and atypic manifestation of a visceral tuberculosis.

[A French soldier returns from the Central Africa Republic with hepatitis A: Vaccination failure is possible!]. / Hépatite A au retour de Centrafrique chez un militaire français : les échecs vaccinaux sont possibles !

In stays in tropical countries, the French military, and travelers in general, are exposed to diseases transmitted by the fecal-oral route, some of which are vaccine-preventable. Here we report a 42-yer-old soldier with hepatitis A, which first appeared on his return from a military operation in the Central African Republic. Despite its excellent immunogenicity and a duration of seroprotection extending beyond 20 years in the vast majority of cases, the hepatitis A vaccine can fail. This reminds us of the importance of combining vaccine and non-vaccine prevention in tropical countries, especially in precarious living conditions.

[Mycoplasma pneumoniae encephalitis successfully treated by levofloxacin]. / Méningo-encéphalite aiguë à Mycoplasma pneumoniae de l'adulte traitée avec succès par lévofloxacine.

INTRODUCTION: Mycoplasma pneumonia (MP) infection may be associated with several neurological complications. Encephalitis, which affects children and rarely young adults, is the most frequent. CASE REPORT: A 23-year-old man was admitted for pneumonia with encephalitis. Mycoplasma pneumoniae infection was documented by serology, and polymerase chain reaction in the cerebrospinal fluid. Despite serious initial presentation, outcome was favourable with levofloxacin treatment. CONCLUSION: MP infection should be considered as a potential aetiology in acute encephalitis in young people and in individuals with respiratory symptoms. Antibiotic therapy (fluoroquinolones or macrolides) should be used if MP is strongly suspected or in case of severe acute meningo-encephalitis.

Infectious diseases related aeromedical evacuation of French soldiers in a level 4 military treatment facility: a ten year retrospective analysis.

BACKGROUND: Infectious diseases are a frequent cause of morbidity in French troops deployed abroad. They are usually minor in severity and managed by field practitioners. We aimed to describe the etiological spectrum of travel-related infections in French soldiers evacuated to a level 4 military treatment facility. METHODS: We evaluated the diagnoses of all service members who were medically evacuated from abroad to our infectious diseases department from January 1, 2004 to October 30, 2013. RESULTS: One hundred and twenty five cases, median age 32 years were referred, 117 (94%) were male and 78 (62%) were from the Army. Main areas of deployment were Africa in 80 cases (64%), Afghanistan in 15 cases (12%), and French Guiana in 10 cases (8%). Median time between initial consultation and hospitalization in the reference center was 5 days (IQ 2-7 d). Thirty (24%) immediate aeromedical evacuations were carried out. The top five diagnoses were Plasmodium falciparum malaria (30), fever of unknown origin (15), cerebro-meningeal infections (10), invasive amebiasis (9), and HIV primary infections (9). Thirteen individuals were admitted in ICU. No death was recorded. CONCLUSIONS: Infectious diseases were a rare of cause of medevac. Most of them were preventable. Lethal etiologies were represented by malaria and cerebro-meningeal infections.

[Imported hepatic amebiasis in adults: retrospective study of 58 cases]. / Amœbose hépatique importée de l'adulte : étude rétrospective de cinquante-huit observations.

The authors report the results of a retrospective study of patients hospitalized for serologically- confirmed hepatic amebiasis confirmed by serology in four French military hospitals from January 1, 2002, through December 31, 2012. The study included 58 patients (53 men, 5 women) with a median age of 41 years (range: 25-80). Among them, 34 (59%) were in the military, 10 (17%) were tourists, 10 migrants (15%), and 4 expatriates (5%). For 75%, contamination occurred in sub-Saharan Africa. The qualitative latex test was simple to use and reliable, even in the emergency department. Medical treatment by metronidazole alone was efficacious in 75% of the patients. Indications for drainage must be discussed according to the clinical and laboratory evidence.

Aortic thrombus and multiple embolisms during a Mycoplasma pneumoniae infection.

We report the case of a patient who presented with a thrombus of the aortic arch complicated with splenic, renal and peroneal artery embolisms, associated with transient lupus anticoagulant, during a Mycoplasma pneumoniae infection. The outcome was good under antibiotic and anticoagulant treatment. We also review the medical literature on M. pneumoniae-related thromboses.

The measles outbreak in the French military forces--2010-2011: results of epidemiological surveillance.

OBJECTIVE: Since the start of 2010 there has been a flare-up of measles in France, following on the resurgence observed in 2008. The aim of this study was to present results of the epidemiological surveillance of measles in the French armed forces in metropolitan France and to describe the outbreak that occurred in 2010 and 2011. METHODS: Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were derived from epidemiological surveillance from 1992 to 2011 for the incidence rates and from notification forms completed in 2010 and 2011 by the military practitioners for the description of characteristics of cases. RESULTS: Between January 1992 and July 2010, 833 cases of measles were reported. Since 2002, the mean incidence rate had been 1 case p.100,000. A significant increase in incidence was observed in 2010 (10.1 p.100,000) and in 2011 (41.4 p.100,000). Clusters of cases accounted for 72.3% of cases. Rates were much higher among subjects under 30. Only 68.6% of cases had been previously vaccinated with at least one dose of MMR vaccine. The mean vaccine coverage among contacts of cases was approximated to 54.3%. CONCLUSIONS: The outbreak of measles observed in 2010 and 2011 in the French armed forces followed the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination coverage.