[Care pathway for high urinary tract infection: an update in an emergency department of a French military hospital]. / Parcours de prise en charge des infections urinaires hautes: état des lieux aux urgencies d'un établissement militaire français.

Objectives Assessing the impact of professional practices on a patient's course is an interesting way to optimize health care pathway. The aim of our study is to update and evaluate the compliance to the recommendations of the Societe de Pathologie Infectieuse de Langue Francaise with regards to professional practices and the route of patients admitted to the emergency department of a French military hospital for high urinary tract infection. Patients and methods A retrospective study was carried out on patients admitted to the emergency department and treated for high urinary tract infection from January 1st, 2015 to April 30th, 2015. Clinical and administrative data, medical exams, and antibiotic prescriptions were extracted from computerized patient medical files and from emergency medical files. Results Out of 91 medical cares, 57% were compliant with the recommendations. For 60% of the patients, blood cultures were not argued and in 70% of cases, imaging wasn't justified. Antibiotic prescriptions were not compliant in 31% of cases, mostly due to long prescription durations. Two third of patients received outpatient care. All hospitalizations were argued. Conclusions Drawing up a caring protocol, regularly raising awareness to the good use of antibiotics, as well as reinforcing a cross disciplinary approach will allow optimizing health care pathways for patients coming to the emergency department with high urinary tract infection.

[Evaluation of the Fluo-RAL (RAL) kit for the identification of mycobacteria by fluorescence microscopy]. / Évaluation du kit Fluo-RAL (RAL) pour la recherche de mycobactéries en microscopie à fluorescence.

AIM OF THE STUDY: This study has examined the sensitivity of a commercially available fluorochrome stain, the Fluo-RAL kit (RAL), in comparison to the Degommier's stain as gold standard. MATERIALS AND METHODS: Hundred and thirty-three twin smears, made directly from samples or after their decontamination with N-acetyl-L-cysteine NaOH, were stained, the first slide with the Degommier's method and the second with the Fluo-RAL kit. The samples were 58 sputums, 31 broncho-aspirations, nine gastric lavages, 11 bronchoalveolar lavages, six pleural fluids, two cerebro-spinal fluids, 11 biopsies, two blood cultures and two deep pus. They were examined with 400 × objective under standard fluorescence UV filter by two laboratory technicians independently. The results were expressed with semi-quantitative mean from 0 to 4+. RESULTS: Hundred and thirty-two results were agreed in grading between the two methods: 73 negative smears, nine quantified as rare (1+), 11 as few (2+), 32 as moderate (3+) and seven as numerous (4+). The only discrepant result had concerned a positive smear quantified as 1+ with the Degommier's stain and as 2+ with the Fluo-RAL kit. This discrepancy was confirmed after a second examination. CONCLUSION: After this study, the Fluo-RAL kit was considered as agreed for its daily use in our laboratory. It improves the standardisation of fluorescence microscopy without additional cost or waste of time and reduces the chemical risk in the laboratory. This test, associated with reading using light-emitting diodes, could allow the development of fluorescence microscopy, the higher sensitive method for direct diagnosis of tuberculosis, in poor-resource countries where tuberculosis is a public health problem.

[Performances of the Amplified Mycobacterium Tuberculosis Direct Test in non respiratory specimens (study about 1538 samples)]. / Performances du test "Amplified Mycobacterium Tuberculosis Direct Test" sur les échantillons extrarespiratoires (étude sur 1538 échantillons).

From March 1998 to August 2009, 1538 non-respiratory samples collected from 1182 patients, were tested using the Gen-Probe Amplified Mycobacterium Direct Test™ (AMTD). After decontamination procedure, every sample was tested by AMTD and by culture on solid and liquid media. The "Gold-standard" was considered by the combination of culture results and clinical diagnosis. Tuberculosis was present in 17,59 % (208 patients). For theses 1538 non-respiratory samples (225 culture positive samples, 248 AMTD positive), 279 corresponded to tuberculosis. After resolving the discordant results, the sensitivity, specificity, positive and negative values were 89, 99, 99,6 and 97,3 %.

[Evaluation of the SD BIOLINE TB Ag MPT64 Rapid® for the diagnosis of tuberculosis]. / Évaluation du kit SD BIOLINE TB Ag MPT64 Rapid® dans le cadre du diagnostic de la tuberculose.

The purpose of this study was to evaluate the SD Bioline Ag MPT64 Rapid(®) for identification of the Mycobacterium tuberculosis complex. The method uses an immunochromatographic assay and needs 100 µl of sample taken from liquid culture or colonies suspended. The sensitivity was determined using 99 strains of M. tuberculosis complex and the specificity using 10 nontuberculous mycobacteria and 85 strains other than mycobacteria genus. The test showed excellent sensitivity (99%) and specificity (100%). This technique displays several advantages and is destined to spread in all laboratories and particularly in endemic areas.

[Urine Dipstick Screening tests: can they allow to conclude the absence of a urinary tract infection in diabetic hospitalised patients]. / Evaluation d'une pratique professionnelle : la bandelette urinaire permet-elle d'exclure le diagnostic d'infection urinaire chez le patient diabétique adulte hospitalisé ?

UNLABELLED: Asymptomatic urinary tract infections are common in diabetic patients. The aim of this 10 months prospective study is to evaluate urinary dipstick tests versus cytobacteriological examination to conclude the absence of urinary tract infection in diabetic subjects. Each diabetic patient hospitalised for less than 8 hours and for whom it was decided a cytobacteriological examination was included in the study (141 samples). At the same time (and at patient's bedside) a dipstick urinalisys (glucose, leucocytes, nitrite, blood, protein, and ketone) was carried out. Sensitivity, specificity, negative predictive value, post test probability and negative likehood ratio were calculated. RESULTS: the combination of leucocyte zone with nitrite zone (both negative) has a 85,2% sensitivity, avoids 65% of cytobacteriology, but has an odd ratio at 0,20. Those results are improved when the glucose zone (negative test or less than 4 crosses) is taken into account, with a 96,3% sensitivity, 63,4% cytobacteriology avoided and a negative likehood ratio at 0,06. CONCLUSION: The addition of the glucose test to the usual leucocytes and nitrite tests seems to allow one to conclude the absence of urinary tract infection in diabetic patients; this is worth studying with a more extensive sample.

[Prompt control of an imported carbapenem-resistant Acinetobacter baumanii outbreak in a French intensive care unit]. / Contrôle rapide d'une épidémie par une souche d'Acinetobacter baumanii résistant à l'imipénème importée de pays émergent dans un service de réanimation en France.

OBJECTIVE: to describe the management and control of a limited outbreak of carbapenem-resistant Acinetobacter baumanii (CRAB) outbreak in a French intensive care unit. METHODS: Careful review of the contact's and carrier's files and outbreak management procedures. RESULTS: An undiagnosed CRAB carrier was admitted to our intensive care unit after medical evacuation from Turkey. Despite preventive isolation and contact precautions, a secondary case was diagnosed 5 days after admission of the index case and resulted in the creation of a crisis unit. Prompt management included an epidemiologic investigation with contact screening and follow-up, environmental screening, and additional restrictive measures: isolation room, closure of adjacent rooms, patient cohorting with designated nurses, and reinforcement of contact precautions. CONCLUSIONS: restrictive management of CRAB outbreaks may allow prompt outbreak control and avoid prolonged room closures.

[Septic shock with multiple organ failure after returning from Southeast Asia]. / Choc septique avec défaillance multiviscérale au retour d'Asie du Sud-Est.

For a patient recently returned from a tropical country in intensive care, the leading hypothesis for a fever leading to multiple organ failure is evidently malaria. Nonetheless, many other causes are possible and should be considered: parasites, viruses, and bacteria. A multidisciplinary discussion between specialists in emergency medicine, radiology, pathology, and infectious diseases is essential to start appropriate treatment as quickly as possible without impairing the patient's prognosis.

[An exceptional case of tricuspid infective endocarditis due to Bartonella henseale revealed by an old pulmonary embolism]. / Un cas exceptionnel d'endocardite infectieuse tricuspide à Bartonella henselae révélée par une embolie pulmonaire « vieillie ¼.

We report a case of blood culture-negative tricuspid infective endocarditis revealed after tick bite by repeated pulmonary infection during one year due to septic pulmonary emboli in a 67-year-old farmer woman. Tricuspid vegetation and pulmonary emboli are calcified. Lyme serology is negative. Serologic test and PCR analysis are positive to Bartonella henselae. The evolution is favorable after antibiotic and anticoagulant treatment. Infective endocarditis due to B. henselae is an exceptional complication of cat scratch disease. You have to think about in case of blood culture-negative endocarditis with calcified valvular lesions even without cat bite, tick seems to be vector of the bacteria.

Absence of nucleotide polymorphism in a Plasmodium vivax multidrug resistance gene after failure of mefloquine prophylaxis in French Guyana.

Vivax malaria is widespread and resistance has been described for chloroquine and sulfadoxine-pyrimethamine. We report on evidence of failure of mefloquine prophylaxis in a French soldier who contracted Plasmodium vivax in French Guyana, South America. Despite regular weekly mefloquine prophylaxis (250 mg/d), the patient presented with a first episode of vivax malaria, which was treated by chloroquine alone, then experienced a second crisis in France. The reappearance of the parasites occurred one day after the end of prophylaxis, confirming parasitological and clinical resistance in a non-immune patient. Mefloquine was detected by a liquid chromatography assay in plasma at a level of 1062 ng/ml, which was higher than the expected concentration after five months of weekly prophylaxis. This isolate had no single nucleotide polymorphisms of the pvmdr1 gene at seven allele positions: pvmdr1 N91, Y189, Y976, S1071, F1076, N1079 and D1291, corresponding to codons 86, 184, 939, 1034, 1039, 1042 and 1246 in P. falciparum. This observation of failure of mefloquine prophylaxis against P. vivax, when added to previously reported chloroquine and atovaquone-proguanil failure, strengthens the case for re-evaluating drug policies for vivax malaria and the need for continuous research on molecular markers of drug resistance.

[Subacute meningoradiculomyeloencephalitis due to cryptococcosis infection]. / Méningoradiculomyéloencéphalite subaiguë liée à une infection par Cryptococcus neoformans.

INTRODUCTION: If meningoencephalitis with or without mass lesion (granuloma or abscess) is the most common pattern of CNS cryptococcal infection, intramedullary involvement is very uncommon. EXEGESIS: The authors report an 70-year-old male with Hodgkin's disease treated by chemotherapy then corticosteroids because of pulmonary fibrosis who was presenting for eight days ago, an ataxia, pyramidal syndrome, and bradypsychy. Spinal MRI revealed a gadolinium T1 weighted homogeneous enhancing T4 level intramedullary lesion. CSF had showed 190 GB/mm3 of lymphomonocytes, increased protein level (2.28 g/l), decreased glucose level (1.5 mmol/l) and positivity for crytococcal antigen. Treatment by amphotericine B and flucytosine then fluconazole for six months was instituted and symptoms gradually improved. CONCLUSION: A cryptococcus infection must be searched by antigen in CSF in case of myelopathy isolated or associated with meningoradiculoencephalomyelopathy, specially in patients with a cellular immunodeficience. Antimycotic agents must be firstly used, surgery would be restricted to decompression if aggravation of disease and compressive effect on the adjacent structures radiologically (MRI) became evident. Prolonged treatment is necessary in case of immunodeficience.

[Specificity of immunofluorescent methods detecting malarial antibodies: comparative study in the screening of blood donations]. / Spécificité des techniques sérologiques de dépistage des anticorps anti-paludéens en immunofluorescence: étude comparative dans la pratique de qualification du don de sang.

UNLABELLED: In France, no case of transfusion-transmitted malaria has been reported since 1994, reflecting the efficiency of the blood donations screening. However, an insufficiently specific serological assay leads to an unjustified loss of red cell units. MATERIALS AND METHODS: A retrospective study included 55 sera previously disqualified for the presence of malarial antibodies. We used different assays detecting these antibodies: Paludix, Falciparum-Spot without or with the elimination of natural antiglobulins by two different methods. RESULTS: Using Paludix, 87% of sera were negative (P < 0.001). With the sera treated for the elimination of natural antiglobulins by neutralisation or absorption, Falciparum-Spot(TM) gave respectively 87% and 94.5% of negative results. CONCLUSION: When using assays avoiding non-specific fluorescence, the number of false positive results significantly decreased. Because the number of blood donors travelling in at-risk countries is continuously rising, a sufficiently specific method to detect malarial antibodies should save a lot of red cell units.

[Triple shigellosis in the same patient contracted during operation "Turquoise" in Rwanda]. / Triple shigellose chez un même malade contractée pendant l'opération "Turquoise" au Ruanda.

We report a case of shigellosis observed in a young French sanitary assistant, returning from a refugees camp in Goma after a 5-week stay. Three different species were isolated from stool samples: Shigella flexneri, S. boydii and S. sonnei. This observation raises the matter of a chemical prophylaxis during a short stay in developing countries where sanitary conditions are poor.

[Epidemiology of resistance to antituberculosis drugs in Mycobacterium tuberculosis complex strains isolated from adenopathies in Djibouti. Prospective study carried out in 1999]. / Epidemiologie de la resistance aux antituberculeux des souches du complexe Mycobacterium tuberculosis isolees d'adenopathies a Djibouti. Etude prospective realisee en 1999.

Tuberculosis is a major cause of death in the Republic of Djibouti. Tuberculous lymphadenitis represents about 25% of the clinical forms of tuberculosis in this country. Between January 1999 and April 1999, 196 lymph node specimens were consecutively collected from 153 patients living in Djibouti. Testing of susceptibility to the major anti-tuberculosis drugs was performed by the proportion method. Growth of Mycobacterium tuberculosis complex strains was obtained from specimens of 85 patients including 9 with prior treatment. Strains were identified as Mycobacterium tuberculosis in 78 cases, Mycobacterium canetti in 3, Mycobacterium africanum in 3, and Mycobacterium bovis in 1. Prevalence of HIV infection was 15%. Assessment of primary resistance demonstrated that the overall resistance rate, i.e., resistance to 1 or more drugs, was 18 (21.2%). Results showed resistance to isoniazid (H) in 6 cases (7.1%), rifampicin (R) in 3 (3.5%), ethambutol (E) in 1 (1.2%), streptomycin (S) in 13 (15.3%) and pyrazinamide (Z) in 1 (1.2%). Multidrug resistance (MDR) was found in 2 cases (2.4%). Assessment of acquired resistance demonstrated resistance to H in 4 cases (44%), R in 2 (22%), S in 2 (22%), E in 0, Z in 0 and MDR in 1 (11%). These findings were not significantly different from data obtained from sputum samples analysed between 1997 and 2000 or from those described in a study conducted in 1985.

[Scytalidium dimidiatum pseudodermatophyte, agent of superficial mycoses and phaehyphomycosis]. / Scytalidium dimidiatum pseudodermatophyte agent de mycoses superficielles et de phaehyphomycoses.

Scytalidium dimidiatum is a fungus found mainly in tropical and subtropical zones. Infection can cause a benign disease closely resembling dermatophytosis. In immunocompromised hosts, Scytalidium dimidiatum can also lead to phaehyphomycosis. Although awareness of these hyphae remains limited in developed countries, their incidence is growing due to increasing immigration and tourism. The rising incidence is well illustrated by three patients who presented onyxis and squamous-like manifestations on the arch of the foot upon returning from trips overseas and in whom various treatments were unsuccessful. In all three cases, culture in non-selective Sabouraud medium identified Scytalidium dimidiatum. These findings underline the need for laboratory testing before undertaking local or systemic treatment of onyxis especially since this pathogen can cause systemic disease. Study of ribosome genes showed that Scytalidium hyalinum is an homologous unpigmented mutant form of Scytalidium dimidatum. No antifungal agent has been effective for management of superficial manifestations and prevention depends mainly on the use of appropriate footwear in endemic areas.

[Serum HRP-2 antigens and imported Plasmodium falciparum malaria: comparison of ParaSight-F and ICT malaria P.f]. / Antigénémie HRP-2 et paludisme d'importation à Plasmodium falciparum: comparaison du ParaSight-F et de l'ICT malaria P.f.

Serum levels of HRP-2 antigens against Plasmodium falciparum in 568 venous blood samples collected at two general hospitals were evaluated using the ParaSight-F (Becton-Dickinson) alone (568/568 samples) or in combination (156/568 samples) with the new ICT-Malaria P.f. (ICT-diagnostic). Comparison with the reference method (thin and thick blood smears assessed by two experienced parasitologists) showed that both tests were highly sensitive (93% and 96% respectively) and specific (98% and 98% respectively). The positive predictive values of the two tests were equal (96%) and the negative predicative values were close (96% and 98% respectively). Although both tests provided results within 10 minutes and required no special equipment for interpretation, the ICT-Malaria P.f. test seemed simpler and easier to use than the ParaSight-F test. The ParaSight-F test alone was used to monitor serum antigen levels after treatment in 24 patients. Antigen levels remained positive for at least three days after disappearance of circulating parasites (range: 3 to 28 days). Evaluation of serum levels of HRP-2 antigens can be useful for emergency diagnosis, especially in patients with low circulating parasite levels. The ICT-Malaria P.f. test seems especially suited for in-field use.

[Comparison of techniques used to screen blood donations for malaria antibodies]. / Comparaison de techniques de dépistage des anticorps antipaludiques utilisées en transfusion.

In France all but one of the serological tests used to screen blood donations rely on ELISA-based techniques. The exception is malaria antibody detection that is performed by the indirect fluorescent antibody technique using commercially available kits. The reagent kit used at the French Army Blood Bank (FABB) is Falciparum-Spot IF (bioMerieux). However since the antigens in this kit are obtained from group A1 red blood cell cultures, false positive results can occur due to binding of natural antiglobulins. Over a 10-month period at the FABB, we disqualified a total of 55 donations (5.02% of total donations) because of positive Falciparum-Spot IF@1000 test results. Most disqualified donations (84%) involved donations with group O red blood cells. In the present retrospective study, these 55 disqualified donations were used to compare the specificity of three other serological tests used for detection of malaria antibodies: Falciparum-SpotIF after elimination of natural antiglobulins by absorption and neutralization with Witebski reagent and Paludix (Diagast). Use of all three techniques provided a specificity gain of over 87% but elimination using Witebski reagent led to a loss of sensitivity. At the FABB we have been using the Falciparum-Spot IF kit after elimination of natural antiglobulins since April 2001. Only 1.62% of donations tested have been disqualified due to the presence of malaria antibodies including 52% with group O red blood cells.

[The transfusion card: value, limitations]. / La fiche transfusionnelle: intérêt, limites.

The transfusion-sheet is an important document which appears first in the French legislation on May 1985 the 17. Its aim is to keep a close watch over transfusion of red blood cells, platelet concentrates and fresh frozen plasma and also immunohematologic evolution of data for every patient. In spite of its importance for everyone in charge of transfusion practice (physicians, biologists, transfusion center,...), a lot of problems may be observed in the strict and complete updating of the document. Informatisation of all the steps of the medical and biological practice appears of crucial interest to perfect its use.

[Delayed haemolytic transfusion reaction due to anti-JK1 antibody]. / Accident hémolytique retardé post-transfusionnel par allo-immunisation anti-JK1.

INTRODUCTION: The sensitivity of the detection of irregular antibodies (DIA) is one of the fundamental basis of transfusion safety. The production of alloantibodies is the first cause of adverse events following transfusion. CASE REPORT: We report a 77-year-old woman who was transfused and presented with a delayed haemolytic anemia due to anti-JK1 alloimmunization. This event highlights the limits of DIA performed before a transfusion, the hazard of this specific type of antibody and the difficulties of the diagnosis of haemolytic anaemia. The preventive measures necessary to avoid this undesirable effect are reminded. CONCLUSION: Despite the sensitive routine test method, the anti-JK1 antibodies could be missed. We should keep in mind the possibility of an anaemia due to alloantibodies we confronted to an unexplained haemolytic episode.

[Imported malaria at Desgenettes Military Hospital in Lyon, France: a retrospective study of 115 cases from 2006 to 2008]. / Le paludisme d'importation à l'hôpital d'instruction des armées Desgenettes de Lyon en 2006-2008 : étude rétrospective de 115 cas.

PURPOSE: The purpose of this report is to describe the clinical, epidemiologic, and parasitological features and therapeutic modalities associated with cases of imported malaria managed at the Desgenettes Military Hospital in Lyon, France. MATERIAL AND METHODS: Review of the files of all patients treated for imported malaria in the emergency and travel medicine departments of the Desgenettes Military Hospital from January 1, 2006, through December 31, 2008. RESULTS: The study included 115 patients (13 of them French armed forces personnel). Most cases (75.6%) were due to falciparum malaria. Only 28.7% of patients had taken proper malaria prophylaxis. Severe symptoms were seen in none of the ambulatory care patients versus 22.7% of the hospitalized patients. Quinine treatment was used for 67% of ambulatory care patients and 89.4% of those hospitalized. CONCLUSIONS: The epidemiologic features observed in the patients described here are similar to those reported by the French national reference center for imported and autochthonous malaria. The frequent use of quinine for ambulatory treatment was not consistent with current guidelines recommending first-line treatment with atovaquone-proguanil or artemether-lumefantrine.

[Plasmacytosis and dengue fever: an underestimated abnormality?]. / Plasmocytose sanguine et dengue: une anomalie biologique sous-estimée?

INTRODUCTION: A significant peripheral blood plasmacytosis is a rare finding associated with viral infections. We reported five consecutive cases of dengue virus infection, with circulating plasma cells. CASE REPORTS: Three women and two men, aged 26 to 75 years, had returned from French West Indies less than one week before the onset of the symptoms (mean: 2.5 days). The transient blood plasmacytosis was variable in intensity (0.1 to 0.8 G/L) with a maximal level between the fourth and the seventh day following the onset of the symptoms, and was associated in four patients, with activated lymphocytes and lympho-plasma cells. CONCLUSION: Reactive plasmacytosis during dengue fever is common and probably underestimated because it is transient and only identified by careful microscopic examination of a blood smear. Plasmacytosis could be explained by the intensity of the immunological response and the production of large amount of interleukins.