Favorable outcome without corticosteroids during post-artesunate delayed hemolysis with positive direct antiglobulin test in severe imported Plasmodium falciparum malaria, France

OBJECTIVES

Positive direct antiglobulin tests (DATs) have been reported in cases of post-artesunate delayed hemolysis (PADH), but the causal role of auto-immune hemolysis remains unclear. We aimed to analyze a cohort of patients with PADH and DAT during severe malaria.

METHODS

We describe PADH and DAT results in a 7-year multi-center retrospective cohort of patients receiving artesunate for severe imported malaria.

RESULTS

Of 337 patients treated with artesunate, 46 (13.6%) had at least one DAT result within 30 days of treatment initiation, and 25/46 (54.3%) had at least one positive DAT. Among 40 patients with available data, 17 (42.5%) experienced PADH. Patient characteristics were similar for patients with a positive or negative DAT, and DAT positivity was not associated with PADH occurrence (P = 0.36). Among patients, 5/13 (38.5%) with a positive DAT after day 7 experienced PADH, compared to 10/13 (76.9%) of those with a negative DAT after day 7 (P = 0.11). Overall, 41% of patients required blood transfusions, and outcome was favorable without corticosteroids, even in cases of PADH.

CONCLUSIONS

DAT does not appear to be a marker of PADH, but rather an indirect marker of an immune-mediated mechanism. DAT positivity should not lead to the administration of systemic corticosteroids during PADH.

Conjunctival conveyance of SARS-CoV-2 in asymptomatic and non-severe symptomatic COVID-19 patients

INTRODUCTION

The prevalence of ocular conveyance of SARS-CoV-2 has been well described for severe/hospitalized cases, but scarcely reported in asymptomatic and non-severe patients, who are unaware that they are carriers.

MATERIAL & METHODS

This prospective cross-sectional study quantitatively evaluated SARS-CoV-2 shedding on the ocular surface (OS). Conjunctival testing was suggested to all hospital personnel being screened by nasopharyngeal (NP) SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR). Disease symptoms were evaluated using a standardized questionnaire and telephone follow-up 6±3 months later for disease evolution (recovery with/without severe disease).

RESULTS

Four hundred and eighty seven patients were included. From 46 NP SARS-CoV-2-positive subjects (cycle threshold [CT]=24.2±7.1), 13% tested positive at the OS (CT=36.4±2.8). Most SARS-CoV-2-positive subjects were symptomatic (n=40, 87%), while 6 were asymptomatic (being tested as contact cases). Systemic symptoms were not significantly different in OS-positive vs OS-negative subjects, although headache tended to be more frequent in OS-positives (83% vs 54%, P=0.06). None of the OS-positive subjects reported ocular symptoms and none developed severe disease requiring hospitalization or oxygen therapy.

CONCLUSION

SARS-CoV-2 shedding at the OS may occur in asymptomatic and non-severe COVID-19 individuals (including those absent of ocular symptoms). However, the high RT-PCR CT values attained may indicate a low risk of transmissibility via this route.

[Demodex and ocular surface disease]

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Old and new pathogenic Nakaseomyces species: epidemiology, biology, identification, pathogenicity and antifungal resistance

During the previous decades, as the number of immunocompromised patients, the average age of Western populations and the widespread use of indwelling medical devices have increased concomitantly, so has the incidence of infections caused by Candida species. Candida albicans remains the most frequently isolated agent of candidiasis. However, C. glabrata now accounts for a substantial part of clinical isolates, ranking number two among the etiologic agents of either superficial or invasive candidiasis in North America and Europe. Along with C. glabrata and belonging to the Nakaseomyces clade, two new species, C. nivariensis and C bracarensis have recently been described as emerging pathogens. This review provides information on the current state of knowledge on the epidemiology, biology, identification, pathogenicity and antifungal resistance of C. glabrata, C. nivariensis and C. bracarensis.

Very prolonged liposomal amphotericin B use leading to a lysosomal storage disease

Amphotericin B is a powerful polyene antifungal drug used for treating systemic fungal infections and is usually administered for a short period. Side effects after prolonged use are unknown in humans. Here we report the case of a 28-year-old man suffering from chronic granulomatous disease (CGD), treated for invasive cerebral aspergillosis with liposomal amphotericin B (L-AmB) for a very long time (8 consecutive years). We describe the efficacy and safety of this treatment in the long term. Aspergillosis was kept under control as long as L-AmB therapy was maintained, but relapsed when the dose was reduced. No overt renal toxicity was noted. The patient gradually developed hepatosplenomegaly and pancytopenia. Abnormalities of bone marrow were similar to the sea-blue histiocyte syndrome. Liver biopsy showed images of nodular regenerative hyperplasia related to CGD as well as a histiocytic storage disease. We discuss the very prolonged use of L-AmB leading to the development of a lysosomal storage disease.

Usefulness of matrix-assisted laser desorption ionisation-time-of-flight mass spectrometry for identifying clinical Trichosporon isolates

Trichosporon spp. have recently emerged as significant human pathogens. Identification of these species is important, both for epidemiological purposes and for therapeutic management, but conventional identification based on biochemical traits is hindered by the lack of updates to the species databases provided by the different commercial systems. In this study, 93 strains, or isolates, belonging to 16 Trichosporon species were subjected to both molecular identification using IGS1 gene sequencing and matrix-assisted laser desorption ionisation-time-of-flight (MALDI-TOF) analysis. Our results confirmed the limits of biochemical systems for identifying Trichosporon species, because only 27 (36%) of the isolates were correctly identified using them. Different protein extraction procedures were evaluated, revealing that incubation for 30 min with 70% formic acid yields the spectra with the highest scores. Among the six different reference spectra databases that were tested, a specific one composed of 18 reference strains plus seven clinical isolates allowed the correct identification of 67 of the 68 clinical isolates (98.5%). Although until recently it has been less widely applied to the basidiomycetous fungi, MALDI-TOF appears to be a valuable tool for identifying clinical Trichosporon isolates at the species level.

Pneumocystosis: a network survey in the Paris area 2003-2008

The aims of this network group were to collect epidemiological data of PcP cases in 14 hospitals in the Paris area and to determine the Di-Hydro Pteroate Synthase (DHPS) genotypes, genetic markers for possible sulfamide resistance. From January 1, 2003 to December 31, 2008, 993 (mean 166/year) PcP cases have been reported. Sixty-five percent of patients were HIV-positive. The median count of CD4 lymphocytes was 32/mm(3) (30 in HIV-positive patients, 152 in HIV-negative patients). In HIV-positive patients, PcP revealed the HIV infection in 39%. Among 304 PcP occurring in HIV known infected patients, no prophylaxis was prescribed for 64%; cotrimoxazole prophylaxis had been prescribed to 47 patients but only one of them had the right compliance. In HIV-negative patients (264), corticosteroids were prescribed in 59% and cytotoxic chemotherapies in 34%; 78% did not receive prophylaxis. One hundred sixty nine tumoral pathologies and 116 transplantations were notified. The mortality rate was 16% at day 14 (13% in HIV-positive patients, 26% in HIV-negative patients). Mutations in DHPS genes were detected in 18.5% of samples; 12.5% of patients were infected with several strains. The total annual number of cases has been stable for five years but the proportion of HIV-negative patients increased from 25% to 43%.