Clostridium sordellii brain abscess diagnosed by 16S rRNA gene sequencing.

Clostridium sordellii is usually associated with skin and soft tissue infections. We describe the first case to our knowledge of a Clostridium sordellii-associated brain abscess, diagnosed by 16S rRNA gene sequencing, expanding the microbiological spectrum of brain abscesses, with emphasis on the role of 16S rRNA gene PCR in their etiologic diagnosis.

In vivo and in vitro detection of a superantigenic toxin Vbeta signature in two forms of streptococcal toxic shock syndrome.

The aim of this study was to examine the production of superantigenic toxins in vivo and in vitro in two patients with streptococcal toxic shock syndrome (TSS). In the first patient, a woman with puerperal fever and Streptococcus pyogenes peritonitis, flow cytometry of blood cells and in vitro studies of the isolate showed massive expansion of Vbeta 2-positive T cells corresponding to SpeC production. In the second case, involving a patient with streptococcal TSS and purpura fulminans following non-steroidal anti-inflammatory drug (NSAID) therapy, no Vbeta expansion of T cells was observed in vivo, but the SpeC Vbeta signature was also detected in vitro. In this latter patient, NSAID administration and/or severe disseminated infection might partly explain the absence of Vbeta T cell expansion in vivo. Combined in vivo and in vitro detection of a superantigenic toxin Vbeta signature may be useful to determine which superantigenic toxin is involved in individual cases of streptococcal TSS.

[Spinal cord toxoplasmosis in HIV infection]. / Toxoplasmose médullaire au cours de l'infection à VIH.

We report the case of an atypical localization of a spinal cord "toxoplasmic abscess". The 46-year-old patient, HIV-1 positive, was admitted for acute urine retention and gait disorders. MRI revealed a T12-L1 medullary lesion suggesting a tumoral, inflammatory and infectious pathology. The radiological aspect and immunosuppression lead to the initiation of a treatment against Toxoplasma gondii, following the same treatment principles as for cerebral toxoplasmosis. The diagnosis can only be proved by data from autopsy or surgical biopsy, but toxoplasmosis PCR on CSF seems to be an interesting alternative to confirm the diagnosis. According to the literature, PCR is not sensitive enough as a diagnostic tool. Improvement after treatment supported the diagnosis confirmed by PCR.

[Can the thick drop/smear examination for malaria be replaced by a rapid diagnostic test in first intention? The Mayotte experience]. / Peut-on remplacer en première intention le frottis/goutte épaisse par un test de diagnostic rapide pour le diagnostic du paludisme ? L'expérience de Mayotte.

SETTINGS: Malaria is a public health problem in the French island of Mayotte (160,000 inhabitants) in the Indian Ocean. In the late 1990, resistance to chloroquine greatly increased, and so did the number of malaria cases, so that a new health policy had to be adopted. Since 2001, the initial smear/thick drop examination, the results of which took too long to obtain, has systematically been replaced by a rapid diagnosis test (Optimal IT Diamed) in all hospitals and public health centers. METHOD: Epidemiological data of malaria on the island was collected and a prospective study was made from March 2005 to February 2006, on two sites (the emergency department of the main hospital and a rural health centre) on all patients presenting with malaria (104 and 139 cases respectively). RESULTS: The first Optimal IT test diagnosed the condition accurately in 88 and 96% of the cases, respectively. Every time symptoms would persist after negative test results and an Optimal IT test was repeated within three days, the parasitemia level was low (0.08 to 0.66%). Very low parasitemia level was very likely to account for a false negative (test result). CONCLUSIONS: These results concerning malaria (and its epidemiological data) in Mayotte show that the initial use of an Optimal IT test instead of the thin/thick blood smear results in a faster management of patients with malaria, although the Optimal IT test is slightly less sensitive and requires training/practice.

[Vaccination against influenza: results of a study on vaccination coverage among health care workers in the Croix-Rousse Hospital (Hospitals of Lyon)]. / Vaccination contre la grippe: résultats d'une enquête sur la couverture vaccinale du personnel hospitalier à l'hôpital de la Croix-Rousse (hôpitaux de Lyon).

INTRODUCTION: The aim of this study was to evaluate the vaccinal status among Croix-Rousse Hospital workers, attitude towards this vaccination, and the information delivered in order to promote this vaccination. METHODS: Questionnaires were delivered by electronic mailing. RESULTS: Six hundred (and) twenty-nine questionnaires were analyzed (26.7% of hospital workers); 30.7% of responders were vaccinated against influenza, 89.2% of responders were aware of influenza and vaccine. Vaccine coverage was lower in younger workers, non health-care workers, non physician health-care workers, and surgeons who responded. Motivation and reserve varied according to the status, position, and age, with some discrepancies. CONCLUSION: These results suggest implementing a better targeted vaccination campaign, according to the various categories of personnel.

Suspected SARS patients hospitalised in French isolation units during the early SARS epidemic: The French experience.

During the SARS epidemic, many patients were screened according to WHO criteria but never went on to develop SARS. In May 2003, early in the epidemic, we conducted a retrospective study to describe suspected SARS patients hospitalised in France and compared them with documented cases of patients with SARS to evaluate the screening strategy. A total of 117 patients were studied. Only 3.4% had been in close contact with a SARS patient but 73.5% came from an affected area. 67.5% had fever and respiratory symptoms on their admission to hospital. 49.6% had fever and non specific symptoms. Clinical symptoms that were significantly more common among patients with SARS were fever, myalgia, dyspnoea, and nausea or vomiting. Presumed viral fever and respiratory tract infection were the most common diagnosis. Symptoms cannot be distinguished from an early stage of SARS confirming the usefulness of the WHO case definitions in isolation decision to avoid further transmission.

Suspected SARS patients hospitalised in French isolation units during the early SARS epidemic: the French experience.

During the SARS epidemic, many patients were screened according to WHO criteria but never went on to develop SARS. In May 2003, early in the epidemic, we conducted a retrospective study to describe suspected SARS patients hospitalised in France and compared them with documented cases of patients with SARS to evaluate the screening strategy. A total of 117 patients were studied. Only 3.4% had been in close contact with a SARS patient but 73.5% came from an affected area. 67.5% had fever and respiratory symptoms on their admission to hospital. 49.6% had fever and non specific symptoms. Clinical symptoms that were significantly more common among patients with SARS were fever, myalgia, dyspnoea, and nausea or vomiting. Presumed viral fever and respiratory tract infection were the most common diagnosis. Symptoms cannot be distinguished from an early stage of SARS confirming the usefulness of the WHO case definitions in isolation decision to avoid further transmission.

[Common variable immunodeficiency with autoimmune manifestations: study of nine cases; interest of a peripheral B-cell compartment analysis in seven patients]. / Déficit immunitaire commun variable avec manifestations auto-immunes: étude de neuf observations; intérêt d'un immunophénotypage spécifique des lymphocytes B circulants chez sept patients.

PURPOSE: Autoimmune manifestations (AIM) are associated to common variable immunodeficiency (CVI) in about 20 to 25% of the cases. This study presents the clinical, biological characteristics and the evolution of nine patients developing CVI and AIM. A peripheral B-cell compartment analysis has been performed in seven cases. METHOD: This multicenter retrospective study analyses nine patients, six men and three women, within a population of 32 CVI. RESULTS: The mean age was 27 years at the time of diagnosis of AIM and 30 years at the time of diagnosis of CVI. The diagnosis of AIM preceded the diagnosis of CVI in five cases. Thirteen AIM of different types were observed: autoimmune hemolytic anemia (AHA, 3), immune thrombocytopenic purpura (ITP, 2), Evan's syndrome (2), primary biliary cirrhosis (1), rheumatoid arthritis (1), alopecia totalis (1), myasthenia gravis (1). The peripheral B-cell compartment was investigated in seven patients: five patients with autoimmune cytopenia presented with a diminution of memory B cells (CD27+IgD-) and immature B cells (CD21-) levels; the patient with primary biliary cirrhosis and myasthenia gravis had only a diminution of memory B cells level; the last patient with ITP presented with a normal level of memory B cells. Five among the seven patients with autoimmune cytopenia required a specific treatment using corticosteroids, high dosages of intravenous immunoglobulin, then splenectomy after failure of the medical management, with severe infectious complications in one case. CONCLUSION: The association of AIM and CVI is not fortuitous. The most common AIM is autoimmune cytopenia. The peripheral B-cell compartment analyses show that a majority of patients have a defect in memory B-cells. Treatment regimens are not standardized and splenectomy increases the risk of infectious complications.

[Tuberculoma and tuberculous meningeal-radiculitis with paradoxical progression during treatment]. / Tuberculomes et méningoradiculite tuberculeuse d'évolution paradoxale sous traitement.

INTRODUCTION: Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare. OBSERVATION: An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy. DISCUSSION: During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.

[Treatment interruption in HIV infected patients: clinical and biological evolution]. / Interruption thérapeutique chez des patients infectés par le virus de l'immunodéficience humaine: évolution clinique et biologique.

OBJECTIVE: The authors had for aim to evaluate the clinical and biological evolution in HIV-infected patients with viraemia lower than 30,000 copies/mL having decided to interrupt their treatment. PATIENTS AND METHODS: Patients with highly active antiretroviral therapy (HAART) for more than 3 months followed by treatment interruption longer than 1 month were included in a retrospective analysis. RESULTS: Forty-six patients having stopped treatment between November 1999 and July 2003 were included. The median duration of treatment interruption was 9.5 months. During the study, no clinical event occurred for 21 patients, and at least 1 clinical event occurred for the 25 others. The median CD4(+) cell counts (CD4) before and at the end of treatment interruption were 597/mm(3) and 437/mm(3), respectively (P<0.001). The median values of viral load before and at the end of treatment interruption were <50 and 23749 copies/mL, respectively (P<0.001). Among the 26 patients having started a new HAART, pre-treatment interruption and post-new HAART median CD4 (with a median delay after HAART of 9.7 months) were 548 and 432.5/mm(3) (P=0.02). Pre-treatment interruption and post-new HAART median viral load were 131.5 and 94.5 copies/mL (NS). CONCLUSIONS: Treatment interruption must be used with caution in spite of the absence of virological impact, because CD4 cell count after new HAART is lower than CD4 preceding treatment interruption. Treatment interruption is contraindicated for patients with AIDS. Physicians must carefully follow other patients who decide on a treatment interruption.

Polymerase chain reaction detection of cytomegalovirus DNA in peripheral blood leukocytes as a predictor of cytomegalovirus disease in HIV-infected patients.

OBJECTIVE: To describe and evaluate a polymerase chain reaction (PCR) method for early diagnosis and prompt management of cytomegalovirus (CMV) retinitis in HIV-infected patients. METHODS: A total of 110 HIV-infected patients (Centers for Disease Control and Prevention stages II to IV) were sampled sequentially for isolation of CMV from peripheral blood leukocytes (PBL; n = 560) and for amplification of CMV DNA in PBL. Semiquantitative analysis of the PCR product was performed and each PCR-positive specimen was assigned a score between 1+ and 4+ (corresponding to four points on a standard curve of dilutions: 80, 800, 8000 and 80,000 CMV genome copies). RESULTS: Levels of CMV DNA in blood increased with HIV infection stage. We focused on eight patients who developed one or more episodes of retinitis during longitudinal follow-up, in whom we found a strong correlation between viraemia, high PCR signal (3+ or 4+) (P < 0.0001) and clinical symptoms. Relapse was preceded by an increase in CMV DNA and resolution correlated with clearance of CMV DNA from blood. CONCLUSIONS: Persistent high PCR levels always preceded virus isolation and may be the first indication of organ involvement and thus early treatment. PCR scores were consistently useful as indicators of drug efficacy and for monitoring of treatment.

Invasive aspergillosis in patients with acquired immunodeficiency syndrome: report of 33 cases. French Cooperative Study Group on Aspergillosis in AIDS.

PURPOSE: Acquired immunodeficiency syndrome (AIDS)-associated invasive aspergillosis (IA) is a rare condition, which is mainly reported as isolated cases either antemortem or at autopsy. The role of AIDS itself is controversial, because many of the reported patients exhibited the classic risk factors such as neutropenia and steroid therapy. The aims of this study were to report 33 patients with IA during AIDS and their outcome, focusing on the risk factors and the value of diagnostic procedures. PATIENTS AND METHODS: Thirty-three patients from 17 different medical centers in France were retrospectively included in the study. For pulmonary IA, we defined two types of patients: those with "confirmed IA," describing all the patients with histologically proven disease, and those with "probable IA," who had the development of a new pulmonary infiltrate on chest radiograph and a positive bronchoalveolar lavage (BAL) fluid culture for Aspergillus species without identification of other pathogens. For extrapulmonary IA, the diagnostic criteria included both positive histology and culture. RESULTS: Of the 33 cases included in this series, 91% were recorded during the last 3 years (1989 to 1991), suggesting that aspergillosis is an emerging complication in AIDS. Approximately 50% of the patients did not exhibit any classic risk factor, i.e., neutropenia and steroid treatment; almost all patients had a CD4 cell count less than 50/mm3. The mycologic culture from BAL was the method of choice for the diagnosis of invasive pulmonary disease because it was known to correlate well with histologic findings obtained either antemortem or postmortem. Of 28 patients with a positive BAL culture for Aspergillus, 15 underwent a biopsy or autopsy and 14 were positive at histology. Serum antigen detection was positive in only 4 of 16 tested patients. Clinical and radiologic signs did not differ from those observed in neutropenic patients without human immunodeficiency virus, except for the higher incidence of neurologic complications in AIDS. Interestingly, we observed three cases of invasive necrotizing tracheobronchial aspergillosis with acute dyspnea and wheezing. The use of amphotericin B (0.5 mg/kg/d) and/or itraconazole (200 to 600 mg/d) was most often unsuccessful. Only four patients experienced clinical and radiologic improvement. The mean interval between the diagnosis of IA and death was 8 weeks (range: 3 days to 13 months). CONCLUSIONS: This study suggests that aspergillosis is an important life-threatening condition in the advanced stage of AIDS. It requires an early diagnosis with BAL fluid culture and careful therapeutic evaluation.

Epidemiologic features and clinical presentation of acute Q fever in hospitalized patients: 323 French cases.

PURPOSE: To contribute to the knowledge of epidemiologic and clinical features of patients hospitalized with Q fever in France. METHODS: We conducted a retrospective analysis of 22,496 sera submitted between 1982 and 1990 to the French National Reference Center for Rickettsial Diseases (NRC). The diagnosis of acute Q fever was based on an IgG titer greater than or equal to 1:200 and an IgM titer greater than or equal to 1:25 against phase II Coxiella burnetii antigen on an indirect immunofluorescence test (IFA). Fifteen cases prior to 1985 were diagnosed on the basis of a complement fixation titer greater than or equal to 1:8. A serosurvey of blood donors from Marseille was also conducted in 1988 on 924 sera, using IFA with a cutoff titer of 1:25. RESULTS: The serosurvey conducted in 1988 showed a seroprevalence of 4.03%, without age or sex prediction. The incidence rate of acute Q fever detection at the NRC was 0.58 per 100,000 inhabitants over the 9-year period. Three hundred twenty-three clinical cases were diagnosed, rising from 1 in 1982 to 107 in 1990. In patients hospitalized for acute Q fever, there was a significantly higher sex ratio of males to females (2.3), which, coupled with the age distribution, indicated that elder males, who are overrepresented due to our recruitment bias, are more susceptible to C. burnetii infections. The mean age of the patients was 45.5 years, while the risk was increased in the 30 to 39 age group as well as in the 60 to 69 age group. Usual epidemiologic risk factors were found in 20.1% of the cases. Hepatitis (61.9%) was a more common clinical presentation in our patients with Q fever than pneumonia (45.8%). This might reflect differences in strains of C. burnetii or the biology of the host. However, French farmers and stock breeders commonly drink unpasteurized raw milk from their cattle, which might indicate a relationship between hepatitis and infection via the digestive tract. CONCLUSION: Our results indicate that many cases of acute Q fever are undiagnosed. A greater awareness of the disease and more extensive serologic testing of patients with symptoms compatible with Q fever may improve the situation.

Severe falciparum malaria (21 cases).

The incidence of severe falciparum malaria is increasing in the developed countries and mortality remains high despite progress in intensive care management and schizonticide treatment. Many authors emphasize the importance of exchange transfusion (EXT) in the most severe cases. We studied 21 cases (34 +/- 12 years, 6 females; SAPS: 8.4 +/- 3.7) of severe malaria (according to WHO criteria) consecutively admitted to ICU between 1985 and 1990: 3 patients underwent EXT. Twenty were febrile above 39 degrees C, 10 had cerebral malaria, 14 hepatic impairment, 8 acute renal failure, 5 pulmonary oedema. Nine patients required mechanical ventilation, 1 haemodialysis, 1 intracranial pressure monitoring. Mean parasitemia was 13%, 16 patients had thrombocytopenia less than 50 x 10(9)/l, 3 anemia less than 7 g/dl and 3 leucopenia less than 2.8 x 10(9)/l. Nineteen received quinine i.v., 1 mefloquine, 1 chloroquine. Sixteen patients received blood products transfusion, 3 were treated by EXT in addition. Twenty were cured and discharged from hospital without sequelae (mean stay: 14 days); 4 had nosocomial infection, 1 a splenic infarction. One patient (17-years-old; SAPS: 17; parasitemia: 7.8%) died 12 h after admission from non-cardiogenic pulmonary oedema with multi-organ failure. The literature and this study lead us to propose EXT in patients with unfavourable evolution after conventional treatment rather than in all the patients with a parasitemia above 10% at admission. A randomized study to compare conventional treatment in ICU with or without EXT is necessary.

[Value of the use of the oral route versus the injectable route for fluoroquinolones. Pharmacoeconomic incidence and bibliographical study]. / Intérêt de l'utilisation de la voie orale par rapport à la voie injectable pour les fluoroquinolones. Incidence pharmacoéconomique et étude bibliographique.

The aim of this study was to research the optimal conditions to shift to oral from injectable administration route for the fluoroquinolone antibiotics and the pharmacoeconomic and therapeutic impact of such a shift. Two indicators were used: proportion of the two administration routes, and mean cost per administration. The published results of pharmacokinetic studies in healthy and diseased subjects, and the clinical and/or pharmacokinetic studies including the notion of a therapeutic shift from the parenteral route to the oral route have been selected. The bioequivalence pharmacokinetic parameters of oral and injectable forms and the major clinical data of the therapeutic shift have been listed. Literature analysis reveals that there are few studies covering the specific assessment of the switch. The financial consequences of oral administration early use show the importance of such studies.

[Chemotherapy for human immunodeficiency virus infection. Current status and perspectives]. / Chimiothérapie de l'infection par le virus de l'immunodéficience humaine. Etat actuel et perspectives.

The role of drugs inhibiting viral replication in patients infected with HIV has been confirmed. Until now only dideoxynucleosides, which are reverse transcriptase inhibitors, have demonstrated antiviral activity in humans. A number of compounds acting on other steps of the viral cycle are currently being evaluated and clinical trials are being performed. Some investigators are attempting to inhibit the binding of viral particles to target cells and their penetration into these by acting on the interaction between HIV ant the CD4 molecule. Another approach consists in the characterization of enzymatic activities which are specific of HIV, other than reverse transcriptase, such as ribonuclease H, integrase or protease, in order to prepare specific inhibitors. Attempts are made to inhibit retroviral gene expression and production of viral particles in infected cells. The development of new nucleoside analogues and drugs with mechanisms of action and toxicities different from those of zidovudine should allow in the near future combination chemotherapy of HIV infection.

[Actinomyces meyeri disseminated actinomycosis disclosing pulmonary carcinoma]. / Actinomycose disséminée à Actinomyces meyeri révélatrice d'un carcinome pulmonaire.

The diagnosis of severe actinomycosis parallel to that of neoplasia leads to speculation of a possible fortuitous association. Because underlying conditions such as immuno-suppression are suspected in such disease, and to strengthen this hypothesis, we report one more case of disseminated actinomycosis associated with a malignant disease, namely an epidermoid pulmonary carcinoma. The diagnosis was made by thoracotomy a few months after the infectious episode. Two years later the patient recovered. The analysis of the literature data is in favor of a fortuitous association between both diagnoses.

[Pubic osteomyelitis in athletes]. / Les ostéomyélites du pubis de l'athlète.

INTRODUCTION: Pubic osteomyelitis has been described in three situations: children in whom Staphylococcus aureus is the preeminent pathogen; elderly patients who have undergone genitourinary procedures, and parenteral drug abusers. In contrast, pubic osteomyelitis in athletes has been described less often. We report three cases of acute staphylococcal pubic osteomyelitis in young athletic men and present a review of the literature. EXEGESIS: The clinical presentation in each case was acute groin, hip, or perineal pain; fever; inability to bear weight; and pubic symphysis tenderness. The diagnosis was established by blood culture and radiologic changes. CONCLUSIONS: Staphylococcus aureus pubic osteomyelitis should be suspected in athletes who have febrile hip or groin pain. The pathogenesis of this disease is thought to involve preexisting trauma or athletic injury and subsequent seeding of this area during transient bacteremia. Prolonged antimicrobial therapy is required for the cure, and debridement with curettage may be necessary if patients have persistent infection or sequestra.

[Macrolides: indications in 1997]. / Les macrolides: indications en 1997.

A GROWING CLASS OF ANTIBIOTICS: Since the discovery of erythromycin, teh prototype macrolide, this class of antibiotics has grown considerably. Roxithromycin, a semi-synthetic erythromycin derivative, has an improved absorbability, tolerability and stability profile. WIDE INDICATIONS: Current indications for these new compounds for respiratory tract infections are presented and discussed in terms of the most recent consensus conferences. NEW TRENDS: All current indications (expecting the respiratory tract) are discussed in light of current perspectives for this family of antibiotics. Growing interest in new bacterial species such as Mycobacterium avium intracellulare, Helicobacter pylori as well as Chlamydia pneumoniae and Mycoplasma pneumoniae contribute to new trends in antibiotics prescription.

[Severe pulmonary varicella in 7 non-immunodepressed adults]. / Varicelle pulmonaire grave chez 7 adultes non immunodéprimés.

We report seven cases of seven pulmonary varicella occurring in seven adults without any previous history of known immunological deficit. In all the cases the vesicular eruption was diffuse, occurring after contact with a child presenting with benign varicella. The respiratory signs appeared five to seven days after the cutaneous signs. On admission there was significant hypoxaemia (PaO2 = 35 to 47 mmHg on air), requiring positive pressure expiration (10 to 18 cmH2O) on mechanical ventilation (4 times) or spontaneous ventilation (3 times). The pulmonary radiographs showed diffuse nodular interstitial shadowing. Treatment consisted of Acyclovir (10 mg/kg/8 h). Five patients were cured without any sequellae five to six days after ventilation. One patient died (3 months pregnant), 1 patient presented with a superinfection with staphylococcus aureus. The occurrence of respiratory signs in an adult presenting with varicella requires hospitalisation for treatment with Acyclovir and also the prevention of superinfections.