Enhancing sexual health and empowerment among migrant women sex workers: a community health worker-led intervention in Marseille, France

Introduction

Given the high infection rate of sexually transmitted infections (STI) among migrant women sex workers (WSWs), it is necessary to understand how to improve prevention, information and care for this vulnerable population. Community health workers (CHWs), by linking community to health services, are positioned to improve health outcomes in migrant communities. This article aims to describe a pilot innovative intervention performed by CHWs to improve sexual health in migrant WSWs.

Methods

This one-year intervention study used a respondent-driven sampling (RDS) to recruit a representative cohort of migrant WSWs in Marseille, France. Four CHWs were recruited from different communities and participated in all stages of the research. They performed individual and group interventions of prevention, support in care and empowerment. Data on participant characteristics, type of intervention and adherence to the intervention were reported via questionnaires given to participants. Simultaneously, semi-structured interviews and informal interviews of migrant WSW, CHWs and care providers were carried out.

Results

A total of 132 migrant WSWs were included in the cohort. Very few of them knew about PrEP (12%) or already used HIV post-exposure treatment (9%). Migrant WSWs were often victims of rape or racism, 15 and 21%, respectively. In two-thirds of cases the level of health literacy was low. Participants suffered from a combination of vulnerability factors: difficulties with access to social rights, food or housing. Only 13% reported having benefited from medical follow-up or assistance by an NGO in the 3 months prior to the program. By 3 months, more than one third of the participants had been tested for HIV (35%) and 63% knew about PrEP. A total retention rate of 70% was reported in the cohort after 6 months.

Conclusion

CHWs enabled to improve care access for migrant WSWs by improving the collaboration between care and social actors at a local level. Through these "bring-back-to" interventions for this hard-to-reach population, CHWs enabled an optimization of the care pathway. Our results also highlight the importance of a population-based approach for individual and group support of empowerment interventions in order to strengthen their capacity for action.

Yellow fever vaccine-associated neurologic and viscerotropic disease: a 10-year case series of the French National Reference Center for Arboviruses with clinical and immunological insights

BACKGROUND

Immunization against the Yellow fever virus (YFV) with the 17D live-attenuated vaccine is the most effective way to prevent the disease. However, unexpected severe adverse events can occur. They consist in a neurological impairment - neurological disease (YEL-AND), a YF-like illness - viscerotropic disease (YEL-AVD) or anaphylaxis. In this article, we describe the epidemiology, clinical and biological features of YEL-AND and YEL-AVD cases reported to the French National Reference Center for Arboviruses (NRCA) in the past 10 years.

METHODS

We conducted a national, retrospective study using the database of the NRCA from June 2012 to June 2022. All patients whose biological samples were sent to the NRCA for detection of YFV by serology and/or RT-qPCR for a suspected vaccine-associated adverse event were included. We collected data by reading medical records and conducted complementary neuro-immunological analysis, followed by a search for autoimmunity against type-1-interferon when samples were available at the NRCA.

RESULTS

There were 10 cases of YEL-AND and 2 cases of YEL-AVD reported to the NRCA in the past 10 years, which represented an overall incidence of 0.6 for 100 000 doses. A total of 6/12 cases were previously healthy patients (50%, mean age 31 years), and 4/12 cases had cardiovascular co-morbidities (42%, mean age 56 years). The majority of YEL-AND had a favourable outcome at 6 months of follow up. One YEL-AVD patient passed. In secondary analyses, we evidenced a significant blood cerebrospinal fluid (CSF) barrier dysfunction, without intrathecal synthesis of immunoglobulin and without argument for a neuron damage. We further detected a significant rate of anti-type-1alpha interferon antibodies in 3/10 tested patients (2 YEL-AND and 1 YEL-AVD).

CONCLUSION

YEL-AND and YEL-AVD are rare events that can underlie defect in the innate immunity of apparently healthy or mild co-morbid subjects. Outcome was generally favourable in the YEL-AND cases of our series, but still life-threatening or even fatal in the YEL-AVD cases.

Is there Lyme borreliosis in French Guiana? Descriptive study among patients referred for a suspected Lyme borreliosis in an Amazonian hospital between 2010 and 2022

Lyme borreliosis (LB) existence in South America is debated, especially in the Amazon region. The infection with Lyme borreliae has never been reported in French Guiana where Borrelia burgdorferi sensu lato is not found in ticks. We describe the final diagnosis and presumed place of acquisition in patients consulting for suspicion of LB. We retrospectively collected data from all consecutive patients consulting for a suspicion of LB between 2010 and 2021 at Cayenne Hospital, French Guiana. Patients were classified by an adjudication committee as confirmed LB if they met the criteria of the French consensus, as possible LB if they had compatible symptoms and a good outcome after appropriate treatment, or excluded when a differential diagnosis was found. The place of acquisition was discussed in case of possible or confirmed case. Twenty-six patients were included. Rheumatologic symptoms were the most reported (88 %) followed by neurological symptoms (61 %). Twenty-four (92 %) of these patients were born out of French Guiana. Diagnosis of LB was considered as confirmed in 2 patients (8 %), for whom the place of acquisition was likely mainland France, and as possible in 3 patients (11 %) with early localized LB presumably acquired in French Guiana. Functional somatic disorders were diagnosed in 13 (50 %) patients whereas 9 (35 %) were found with another disease. This study did not confirm the acquisition of LB in French Guiana. However, three possible autochthonous cases encourage clinicians working in the Amazon area to stay aware of LB.

Erythema Migrans Caused by Borrelia spielmanii, France

We describe a rare case of early Lyme borreliosis in France caused by Borrelia spielmanii, which manifested as a large erythema chronicum migrans rash. The patient completely recovered after a 15-day course of amoxicillin. Absence of pathognomonic signs prevented distinguishing B. spielmanii from other etiologies as cause in this case-patient.

Clinical and Epidemiological Aspects of Acute Q Fever in Reunion Island over Fourteen Years: A Retrospective Cohort Study

The clinical characteristics and epidemiology of Q fever in the Tropics are poorly described. We performed a retrospective cohort study of hospitalized cases between 2004 and 2017 in Reunion Island. Acute Q fever was defined in presence of a positive serology (phase II IgG ≥ 200 and phase II IgM ≥ 50), or a seroconversion (4-fold increase in phase II IgG between paired samples), or a positive PCR (blood or serum). Forty-two cases matched the diagnostic criteria. The most common clinical manifestations were fever (85.7%) and pulmonary symptoms (61.9%), including pneumonia (45.2%). Ninety percent of the patients were living in a farming area. Cumulative incidence was estimated at 9.3 per 100,000 inhabitants (95%CI: 6.4-12.1) with cases diagnosed yearly all throughout the study period except in 2006. Together with the seroprevalence figures, these data suggest that Q fever reaches low to moderate endemic levels on Reunion Island. As previously reported, pulmonary symptoms are in the foreground.

Effectiveness of a Community Empowerment Intervention to Improve Access to Pre-exposure Prophylaxis in Migrant Women Sex Workers: Protocol for a Mixed Methods Implementation Study

BACKGROUND

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection. However, at-risk women very rarely use PrEP in France-this represents a critical issue among migrant women sex workers (MWSWs). Previous studies on PrEP use among women sex workers or migrants focused on individual or social determinants of motivation. However, operational studies in real-word settings using a holistic population approach to maximize PrEP adherence among MWSWs are lacking.

OBJECTIVE

FASSETS (ie, "Favoriser l'Accès à la Santé Sexuelle des Travailleuses du Sexe"; English: "facilitate the access to Sexual Health in women sex workers") is a participative, multilevel, mixed methods study aiming to improve global knowledge of and access to sexual health care and PrEP among MWSWs through targeted empowerment strategies.

METHODS

This study comprises several phases: (1) phase 1: an initial qualitative study combining semistructured interviews, informal interviews, and participative observations will be performed among MWSWs, local community nongovernmental organizations, and institutions providing sexual reproductive health services to identify the determinants of PrEP access among MWSWs and for respondent-driven sampling (RDS); (2) phase 2: the size of the hidden MWSW population is estimated in Marseille through capture-recapture (the RDS survey will serve as "recapture"); (3) phase 3: a longitudinal cohort will be formed through RDS to represent the MWSW population with a goal of 150 inclusions-this cohort will be followed up for 12 months, and sequential questionnaires exploring medical history; knowledge of sexual health, HIV, and sexually transmitted infections; migration route; and current living conditions will be administered at inclusion (month 0) and months 3, 6, and 12 to measure the following interventional phase's outcomes; and (4) phase 4: an interventional study with community empowerment actions about sexual health and PrEP will be conducted with community health workers; standardized questionnaires and semistructured interviews, observations, and focus groups will highlight MWSWs' experiences with empowerment resources, concerns about sexual health, and especially PrEP use or uptake, and we will evaluate whether and how community-adapted empowerment actions conducted by community health workers are effective in increasing access to sexual health, prevention and screening of sexually transmitted infections, and PrEP knowledge and access among MWSWs.

RESULTS

Recruitment commenced on March 1, 2022. We estimate the follow-up period to end on September 30, 2023.

CONCLUSIONS

This multiphase study will provide robust evidence about the magnitude of the MWSW population in Marseille (the second largest town in France) and their current conditions of living, access to and knowledge of sexual health, and PrEP access. Using a mixed methods analysis, we will investigate whether individual and collective community health empowerment approaches can facilitate access to PrEP and its initiation, use, and adherence in this vulnerable population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42844.

When the patient is making the (wrong?) diagnosis: a biographical approach to patients consulting for presumed Lyme disease

BACKGROUND

Media coverage of Lyme disease (LD) has led to an increase in consultations for presumed LD in Europe. However, LD is confirmed in only 10%-20% of patients, with a significant number remaining in a diagnostic dead-end.

OBJECTIVES

To reach a deeper understanding of how patients themselves contribute to the diagnostic process. To describe the genesis of the LD hypothesis in care pathways.

METHODS

In 2019, 30 patients from a prospective cohort consulting in the infectious diseases department at University Hospital in Marseille for presumed LD were recruited for semistructured interviews. The inclusion criteria were: suffering from subjective symptoms for 6 months, no clinical or paraclinical argument suggesting current LD. The patients' medical trajectories were collected using a biographical approach.

RESULTS

The diagnosis of LD was primarily triggered by identification with personal testimonies found on the Internet. Most of patients were leading their own diagnostic investigation. The majority of participants were convinced they had LD despite the lack of medical evidence and the scepticism of their referring GP.

CONCLUSION

GPs should first systematically explore patients' aetiologic representations in order to improve adherence to the diagnosis especially in the management of medically unexplained symptoms. Long COVID-19 syndrome challenge offers an opportunity to promote active patient involvement in diagnosis.

Q Fever as a Cause of Community-Acquired Pneumonia in French Guiana

In French Guiana, community-acquired pneumonia (CAP) represents over 90% of Coxiella burnetii acute infections. Between 2004 and 2007, we reported that C. burnetii was responsible for 24.4% of the 131 CAP hospitalized in Cayenne. The main objective of the present study was to determine whether the prevalence of Q fever pneumonia remained at such high levels. The secondary objectives were to identify new clinical characteristics and risk factors for C. burnetii pneumonia. A retrospective case-control study was conducted on patients admitted in Cayenne Hospital, between 2009 and 2012. All patients with CAP were included. The diagnosis of acute Q fever relied on titers of phase II IgG ≥ 200 and/or IgM ≥ 50 or seroconversion between two serum samples. Patients with Q fever were compared with patients with non-C. burnetii CAP in bivariate and multivariate analyses. During the 5-year study, 275 patients with CAP were included. The etiology of CAP was identified in 54% of the patients. C. burnetii represented 38.5% (106/275; 95% CI: 31.2-45.9%). In multivariate analysis, living in Cayenne area, being aged 30-60 years, C-reactive protein (CRP) > 185 mg/L, and leukocyte count < 10 G/L were independently associated with Q fever. The prevalence of Q fever among CAP increased to 38.5%. This is the highest prevalence ever reported in the world. This high prevalence justifies the systematic use of doxycycline in addition to antipneumococcal antibiotic regimens.

Exploring convolutional neural networks with transfer learning for diagnosing Lyme disease from skin lesion images

BACKGROUND AND OBJECTIVE

Lyme disease which is one of the most common infectious vector-borne diseases manifests itself in most cases with erythema migrans (EM) skin lesions. Recent studies show that convolutional neural networks (CNNs) perform well to identify skin lesions from images. Lightweight CNN based pre-scanner applications for resource-constrained mobile devices can help users with early diagnosis of Lyme disease and prevent the transition to a severe late form thanks to appropriate antibiotic therapy. Also, resource-intensive CNN based robust computer applications can assist non-expert practitioners with an accurate diagnosis. The main objective of this study is to extensively analyze the effectiveness of CNNs for diagnosing Lyme disease from images and to find out the best CNN architectures considering resource constraints.

METHODS

First, we created an EM dataset with the help of expert dermatologists from Clermont-Ferrand University Hospital Center of France. Second, we benchmarked this dataset for twenty-three CNN architectures customized from VGG, ResNet, DenseNet, MobileNet, Xception, NASNet, and EfficientNet architectures in terms of predictive performance, computational complexity, and statistical significance. Third, to improve the performance of the CNNs, we used custom transfer learning from ImageNet pre-trained models as well as pre-trained the CNNs with the skin lesion dataset HAM10000. Fourth, for model explainability, we utilized Gradient-weighted Class Activation Mapping to visualize the regions of input that are significant to the CNNs for making predictions. Fifth, we provided guidelines for model selection based on predictive performance and computational complexity.

RESULTS

Customized ResNet50 architecture gave the best classification accuracy of 84.42% ±1.36, AUC of 0.9189±0.0115, precision of 83.1%±2.49, sensitivity of 87.93%±1.47, and specificity of 80.65%±3.59. A lightweight model customized from EfficientNetB0 also performed well with an accuracy of 83.13%±1.2, AUC of 0.9094±0.0129, precision of 82.83%±1.75, sensitivity of 85.21% ±3.91, and specificity of 80.89%±2.95. All the trained models are publicly available at https://dappem.limos.fr/download.html, which can be used by others for transfer learning and building pre-scanners for Lyme disease.

CONCLUSION

Our study confirmed the effectiveness of even some lightweight CNNs for building Lyme disease pre-scanner mobile applications to assist people with an initial self-assessment and referring them to expert dermatologist for further diagnosis.

[Borreliosis and relapsing fever]

BORRELIOSIS AND RELAPSING feverrelapsing fevers borreliosis (RFB) are caused by bacteria of the genus Borrelia, within the spirochete's family, transmitted to Humans by arthropods (lice Pediculus humanus, soft ticks of the genus Ornithodoros, or hard ticks for one of them). The RFB transmitted by body lice is cosmopolitan and occurs during epidemics in the context of major crises (promiscuity, precarious hygiene conditions, food crises, etc.). RFB transmitted by ticks are distributed by region, according to the Borrelia species and the geographical repartition of the tick involved (sporadic transmission). The incubation period varies from 3 to 20 days. The first febrile phase lasts 3 days (1-14 days), followed by a phase of apyrexia with persistence of other clinical signs (skin rash, petechiae, headaches, agitation, polyarthromyalgia, abdominal pain, nausea/vomiting, etc.). The recurrence of fever occurs every 7 days on average. Bacteremia in the blood is abundant during fever allowing direct diagnosis by microscopy, Borrelia PCR or culture on a specific medium when available. The first-line treatment is doxycycline, except in case of neurological involvement (ceftriaxone). The mortality Rate varies from 2 to 5 % depending on the Borrelia Species involved. The outcome is usually good after treatment.

"Chiclero's Ulcer" Due to Leishmania mexicana in Travelers Returning from Central America: A Case Report and Review of the Literature

Cutaneous leishmaniasis (CL) due to a New World species of Leishmania is increasingly seen among returning international travelers, and most cases arise from travel to Mexico, Central and South America. We described a case of CL in a women presenting a nonhealing ulceration under her right ear with slight increase of size of the left parotid gland under the skin lesion, evolving for 4 months. In her history of travel, she reported a ten-day stay in Mexico during the Christmas vacation in the Yucatan region with only half a day walking in the tropical forest. Diagnosis of CL due to Leishmania mexicana was done via PCR detection and sequencing from swab sampling of the lesion. The patient recovered without antiparasitic treatment. Clinicians should consider diagnosing Chiclero’s ulcer in patients returning from endemic areas such as Central America and Texas who present with chronic ulceration. A noninvasive sampling is sufficient for the PCR-based diagnosis of this disease.

Evaluation of pain susceptibility by taking blood pressure in patients with infections: A prospective comparative study

Pain sensitization leading to polyalgia can be observed during infectious diseases. The blood pressure cuff-evoked pain threshold (BPCEPT) has been used in previous studies as a screening tool for fibromyalgia.We aimed to use the BPCEPT as a screening test for detecting pain sensitization in patients suffering from infectious diseases. We also investigated whether specific factors were associated with pain sensitization.We performed a prospective comparative study including all patients of our infectious diseases center in a 1-year period. We created a positive control group of patients suffering from fibromyalgia and a negative control group of "apparently healthy" patients consulting for vaccination.The blood pressure (BP) cuff was inflated until the patient signaled that they experienced pain, and this pressure value was noted.A total of 2355 patients were included. The positive control group had significantly lower values of the BPCEPT than all other groups. Among hospitalized patients with infectious diseases, a low BPCEPT was significantly associated with high temperature (P < .0001), older age (P = .002), being a woman (P = .004), high serum glutamic-oxaloacetic transaminase (P = .007), and high C reactive protein levels (P = .02). Moreover, in multivariate analysis, respiratory infection, meningitis, urinary tract infection, febrile neutropenia, and Q fever were independently associated with a low BPCEPT. A significant negative dynamic correlation between the BPCEPT and temperature was also observed (P < .001).We demonstrated for the first time in a large sample of patients that the BPCEPT method can be used to detect pain susceptibility. We observed a significant dynamic correlation between pain sensitization and temperature. Additionally, pain sensitization was associated with some diseases, suggesting that they trigger pain sensitivity.

Polymicrobial Infections Among Patients with Vascular Q Fever, France, 2004-2020

We report 5 cases of vascular Q fever complicated by polymicrobial superinfection in patients who had no risk factors for acute Q fever. Q fever was diagnosed by serologic and molecular assays for Coxiella burnetii. We confirmed additional infections using conventional graft cultures.

Human Q Fever on the Guiana Shield and Brazil: Recent Findings and Remaining Questions

Purpose of Review

In this review, we report on the state of knowledge about human Q fever in Brazil and on the Guiana Shield, an Amazonian region located in northeastern South America. There is a contrast between French Guiana, where the incidence of this disease is the highest in the world, and other countries where this disease is practically non-existent.

Recent Findings

Recent findings are essentially in French Guiana where a unique strain MST17 has been identified; it is probably more virulent than those usually found with a particularly marked pulmonary tropism, a mysterious animal reservoir, a geographical distribution that raises questions.

Summary

Q fever is a bacterial zoonosis due to Coxiella burnetii that has been reported worldwide. On the Guiana Shield, a region mostly covered by Amazonian forest, which encompasses the Venezuelan State of Bolivar, Guyana, Suriname, French Guiana, and the Brazilian State of Amapá, the situation is very heterogeneous. While French Guiana is the region reporting the highest incidence of this disease in the world, with a single infecting clone (MST 117) and a unique epidemiological cycle, it has hardly ever been reported in other countries in the region. This absence of cases raises many questions and is probably due to massive under-diagnosis. Studies should estimate comprehensively the true burden of this disease in the region.

Low Dose Chest CT and Lung Ultrasound for the Diagnosis and Management of COVID-19

BACKGROUND

The COVID-19 pandemic has provided an opportunity to use low- and non-radiating chest imaging techniques on a large scale in the context of an infectious disease, which has never been done before. Previously, low-dose techniques were rarely used for infectious diseases, despite the recognised danger of ionising radiation.

METHOD

To evaluate the role of low-dose computed tomography (LDCT) and lung ultrasound (LUS) in managing COVID-19 pneumonia, we performed a review of the literature including our cases.

RESULTS

Chest LDCT is now performed routinely when diagnosing and assessing the severity of COVID-19, allowing patients to be rapidly triaged. The extent of lung involvement assessed by LDCT is accurate in terms of predicting poor clinical outcomes in COVID-19-infected patients. Infectious disease specialists are less familiar with LUS, but this technique is also of great interest for a rapid diagnosis of patients with COVID-19 and is effective at assessing patient prognosis.

CONCLUSIONS

COVID-19 is currently accelerating the transition to low-dose and "no-dose" imaging techniques to explore infectious pneumonia and their long-term consequences.

18F-FDG brain PET hypometabolism in patients with long COVID

PURPOSE

In the context of the worldwide outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), some patients report functional complaints after apparent recovery from COVID-19. This clinical presentation has been referred as "long COVID." We here present a retrospective analysis of ¹⁸F-FDG brain PET of long COVID patients from the same center with a biologically confirmed diagnosis of SARS-CoV-2 infection and persistent functional complaints at least 3 weeks after the initial infection.

METHODS

PET scans of 35 patients with long COVID were compared using whole-brain voxel-based analysis to a local database of 44 healthy subjects controlled for age and sex to characterize cerebral hypometabolism. The individual relevance of this metabolic profile was evaluated to classify patients and healthy subjects. Finally, the PET abnormalities were exploratory compared with the patients' characteristics and functional complaints.

RESULTS

In comparison to healthy subjects, patients with long COVID exhibited bilateral hypometabolism in the bilateral rectal/orbital gyrus, including the olfactory gyrus; the right temporal lobe, including the amygdala and the hippocampus, extending to the right thalamus; the bilateral pons/medulla brainstem; the bilateral cerebellum (p-voxel < 0.001 uncorrected, p-cluster < 0.05 FWE-corrected). These metabolic clusters were highly discriminant to distinguish patients and healthy subjects (100% correct classification). These clusters of hypometabolism were significantly associated with more numerous functional complaints (brainstem and cerebellar clusters), and all associated with the occurrence of certain symptoms (hyposmia/anosmia, memory/cognitive impairment, pain and insomnia) (p < 0.05). In a more preliminary analysis, the metabolism of the frontal cluster which included the olfactory gyrus was worse in the 7 patients treated by ACE drugs for high blood pressure (p = 0.032), and better in the 3 patients that had used nasal decongestant spray at the infectious stage (p < 0.001).

CONCLUSION

This study demonstrates a profile of brain PET hypometabolism in long COVID patients with biologically confirmed SARS-CoV-2 and persistent functional complaints more than 3 weeks after the initial infection symptoms, involving the olfactory gyrus and connected limbic/paralimbic regions, extended to the brainstem and the cerebellum. These hypometabolisms are associated with patients' symptoms, with a biomarker value to identify and potentially follow these patients. The hypometabolism of the frontal cluster, which included the olfactory gyrus, seems to be linked to ACE drugs in patients with high blood pressure, with also a better metabolism of this olfactory region in patients using nasal decongestant spray, suggesting a possible role of ACE receptors as an olfactory gateway for this neurotropism.

Microscopic detection of bacillus Calmette-Guérin mycobacteria in bladder biopsy using fluorescence in situ hybridization: Détection microscopique des Bacilles biliés de Calmette et Guérin (BCG) dans une biopsie vésicale par hybridation in situ en fluorescence

Intravesical instillation of Bacilli Calmette Guérin (BCG) as a superficial bladder cancer treatment is generally well tolerated, but local or systemic complications may occur, some of which may be life-threatening. Following the suspicion of post-BCG cystitis in a 72-year-old man with a history of urothelial carcinoma treated by intravesical BCG instillation, we used fluorescence in situ hybridization (FISH) targeting the rpoB gene of the Mycobacterium tuberculosis complex to detect Mycobacterium bovis BCG in paraffin-embedded bladder biopsy sections. FISH yielded specific detection of BCG mycobacteria in the bladder biopsy section, appearing as red-fluorescent bacilli. Treatment with rifampicin, ethambutol and isoniazid is then initiated in combination with corticosteroid therapy.

Case Report: Vibrio cholerae Biliary Tract Infections in Two North Africans in France

The origin of a cholera outbreak may be unclear, as recently in Algeria. In two patients from North Africa, Vibrio cholerae was isolated in the context of hepatobiliary tract infections without any known outbreak. Gallbladder and asymptomatic long-term carriers might play a role in the emergence of cholera.

Autochthonous human and animal leptospirosis, Marseille, France

Autochtonous leptospirosis is an emerging zoonotic disease in Europe, particularly in France. We report a case of leptospirosis in a 36 year-old man, who is a recently arrived migrant from Tunisia and lives in a squat. He suffered from pulmonary and neurological involvement as well as hepatitis. Seven rats (Rattus norvegicus) were trapped in the squat where the patient lived. Leptospira spp. DNA was detected in the kidney of one rat, highlighting the most likely source of contamination. In addition to the classic recreational or professional exposure to fresh water and practice of outdoor sports as a source of leptospirosis contamination, unhealthy living conditions (homeless or squatting) and therefore frequent exposure to rats, are another risk factor for leptospirosis in Europe.

Campylobacter jejuni infection associated with miscarriage, a case report and literature review

Campylobacter jejuni is recognized as a cause of miscarriage in animals, but rarely in humans. We describe here a case of spontaneous miscarriage at 12 weeks of gestation associated with Campylobacter jejuni bacteremia following digestive disorders. The patient was treated with azithromycin with good clinical evolution and underwent uterine aspiration during hospitalization. In our review of the literature, we found only 12 other miscarriages due to C. jejuni infections. Clinicians should consider this cause of miscarriage in febrile pregnant women, as the bacterium is resistant to many beta-lactam antibiotics, and macrolides are the first-line treatment.

Immunoserological Diagnosis of Human Borrelioses: Current Knowledge and Perspectives

Spirochetes of the genus Borrelia are divided into relapsing fever borreliae and Lyme disease borreliae. Immunoserological assays have been poorly developed for relapsing fever borreliae, where direct detection methods are more adapted to the pathophysiology of these infections presenting with massive bacteraemia. However, emergence of the novel agent of relapsing fever B. miyamotoi has renewed interest in serology in this context. In Lyme disease, because direct detection methods show low sensitivity, serology plays a central role in the diagnostic strategy. This diagnostic strategy is based on a two-tier methodology involving a first test (ELISA) with high sensitivity and acceptable specificity and a second, more specific test (western blot) for diagnostic confirmation. The most frequent limitations and pitfalls of serology are cross reactions, false IgM positivity, a seronegative window period at the early time of the infection, and serologic scars with a suspicion of reinfection. International guidelines have thus been proposed to avoid these difficulties with interpretation. Finally, unconventional diagnostic tests have been developed recently in the context of a highly publicized disease, with widely varying results, some of which have no available evidence-based data. New two-tier testing strategies using two ELISA tests (C6 and WCS for example) to replace immunoblot are currently proposed by some authors and guidelines, and promising new tests such as CXCL-13 in CSF are promising tools for the improvement of the diagnosis of Lyme borreliosis.

A sporadic case of acute Q fever and identification of the animal source of the infection

Q fever is a zoonosis. Humans are infected through the inhalation of Coxiella burnetii particles that are dispersed into the air from the birth products or faeces of ruminants. Major outbreaks can occur in association with farming activities. C. burnetii can be disseminated by wind up to several tens of kilometres and infect humans far from its zoonotic source. As a result, the sources of sporadic cases are rarely identified. We report a sporadic case of acute Q fever in a French farmer returning from a cruise in the Caribbean. Careful examination found that the infection was not associated with travel, and a veterinary investigation identified C. burnetii DNA (MST genotype 8) in the faeces, nasal and vaginal swabs of several ewes from her herd of sheep. As a consequence, the herd was slaughtered to avoid dissemination of the infection.

Early treatment of COVID-19 patients with hydroxychloroquine and azithromycin: A retrospective analysis of 1061 cases in Marseille, France

BACKGROUND

In France, the combination hydroxychloroquine (HCQ) and azithromycin (AZ) is used in the treatment of COVID-19.

METHODS

We retrospectively report on 1061 SARS-CoV-2 positive tested patients treated for at least three days with the following regimen: HCQ (200 mg three times daily for ten days) + AZ (500 mg on day 1 followed by 250 mg daily for the next four days). Outcomes were death, clinical worsening (transfer to ICU, and >10 day hospitalization) and viral shedding persistence (>10 days).

RESULTS

A total of 1061 patients were included in this analysis (46.4% male, mean age 43.6 years - range 14-95 years). Good clinical outcome and virological cure were obtained in 973 patients within 10 days (91.7%). Prolonged viral carriage was observed in 47 patients (4.4%) and was associated to a higher viral load at diagnosis (p < .001) but viral culture was negative at day 10. All but one, were PCR-cleared at day 15. A poor clinical outcome (PClinO) was observed for 46 patients (4.3%) and 8 died (0.75%) (74-95 years old). All deaths resulted from respiratory failure and not from cardiac toxicity. Five patients are still hospitalized (98.7% of patients cured so far). PClinO was associated with older age (OR 1.11), severity of illness at admission (OR 10.05) and low HCQ serum concentration. PClinO was independently associated with the use of selective beta-blocking agents and angiotensin II receptor blockers (p < .05). A total of 2.3% of patients reported mild adverse events (gastrointestinal or skin symptoms, headache, insomnia and transient blurred vision).

CONCLUSION

Administration of the HCQ+AZ combination before COVID-19 complications occur is safe and associated with a very low fatality rate in patients.

Routine Culture-Resistant Mycobacterium tuberculosis Rescue and Shell-Vial Assay, France

We used shell-vial assay with a medium that buffered rifampin to isolate routine culture–resistant Mycobacterium tuberculosis bacteria from cerebrospinal fluid and rifampin-containing intervertebral disc and vertebral corpus of a patient in treatment for Pott’s disease and disseminated tuberculosis. Whole-genome sequencing confirmed M. tuberculosis lineage 4 (Euro-American) strain.

Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: A pilot observational study

BACKGROUND

We need an effective treatment to cure COVID-19 patients and to decrease virus carriage duration.

METHODS

We conducted an uncontrolled, non-comparative, observational study in a cohort of 80 relatively mildly infected inpatients treated with a combination of hydroxychloroquine and azithromycin over a period of at least three days, with three main measurements: clinical outcome, contagiousness as assessed by PCR and culture, and length of stay in infectious disease unit (IDU).

RESULTS

All patients improved clinically except one 86 year-old patient who died, and one 74 year-old patient still in intensive care. A rapid fall of nasopharyngeal viral load was noted, with 83% negative at Day7, and 93% at Day8. Virus cultures from patient respiratory samples were negative in 97.5% of patients at Day5. Consequently patients were able to be rapidly discharged from IDU with a mean length of stay of five days.

CONCLUSION

We believe there is urgency to evaluate the effectiveness of this potentially-life saving therapeutic strategy at a larger scale, both to treat and cure patients at an early stage before irreversible severe respiratory complications take hold and to decrease duration of carriage and avoid the spread of the disease. Furthermore, the cost of treatment is negligible.

[West Nile virus infection: an emerging arbovirosis in France and Europe]

West nile virus infection: an emerging arbovirosis in france and europe. West Nile virus is a mosquito-borne flavivirus, transmitted to humans by mosquitoes of the genus Culex, from an avian reservoir. Humans are accidental hosts and there is no report of human-to-human transmission, except via blood transfusion or organ transplantation. In 2018, Europe experienced the largest outbreak of West Nile virus infection ever. In France, 27 cases were identified including 7 neuro invasive forms. This infection is asymptomatic in most cases but may also manifest as an isolated fever or flu-like syndrome. In about 1% of cases, neuro-invasive forms with meningitis, meningoencephalitis or flaccid paralysis can be observed. There is no specific treatment for this viral infection. Prevention is based on the prevention of mosquito bites, but also on enhanced epidemiological surveillance during the period of circulation of the virus in Europe (from spring to autumn).

[Rickettsioses]

Rickettsioses. Rickettsioses are caused by intracellular bacteria from order of rickettsiales. They are transmitted by arthropods, mainly ticks, lice, fleas or other species close to chiggers, mainly in tropical areas. Some rickettsioses are endemic in France and others can be seen in patients returning from travel, including those presenting with "fever of unknown origin". Rickettsiae can't be isolated by conventional blood cultures in the laboratory. The diagnosis of rickettsial diseases is often made by serology, but specific PCR based on the swab of an inoculation eschar when it is present is a simple and rapid tool. The standard treatment for rickettsioses is doxycycline, that should be started as soon as clinical suspicion occurs, before diagnostic confirmation since some rickettsial diseases can be fatal.

Case Report: First Molecular Diagnosis of Liver Abscesses Due to Fasciola hepatica Acute Infection Imported from Vietnam

We report a case of Fasciola hepatica liver abscesses in a 67-year-old female returning from a trip to Vietnam. She has been suffering from a fever, right abdominal pain for 4 days, and major eosinophilia. Radiologic investigations showed multiple hypodense confluent abscesses in the right lobe of the liver, complicated by occlusive thrombosis of the right branch of the portal vein. The serological investigation of helminth-elicited eosinophilia showed only a positive serology for F. hepatica. Despite repeated negative stool examinations for any intestinal pathogen, the diagnosis was established by the detection of F. hepatica DNA in stool and pus aspirate samples.

Cellulitis of the face associated with SENLAT caused by Rickettsia slovaca detected by qPCR on scalp eschar swab sample: An unusual case report and review of literature

BACKGROUND

Tick-borne rickettsioses are infectious diseases caused by obligate intracellular Gram-negative bacteria belonging to the spotted fever groupof Rickettsia.

METHODS

We describe an unusual case of SENLAT (Scalp eschar and neck lymphadenopathy after tick bite), caused byRickettsia slovaca, associated with a cellulitis of the face in a 70-year-old woman, and diagnosed using qPCR on a scalp eschar swab. We review the literature regarding cases of SENLAT-associated-cellulitis and case of SENLAT diagnosed by qPCR on scalp eschar swabs.

RESULTS

We found only one previous report of SENLAT associated with a cellulitis of the face. It was a nine-year-old French girl diagnosed by seroconversion for Rickettsia sp. Our review of the literature showed that qPCR on eschar swab samples is a less invasive method than performing cutaneous biopsy of the eschar and has good sensitivity and specificity (90% and 100%, respectively).

CONCLUSIONS

We report the second case of cellulitis of the face associated with the SENLAT syndrome. Detection of Rickettsia by qPCR on swab sample of the scalp eschar is a simple, noninvasive technique allowing rapid diagnosis and treatment when SENLAT is suspected.

Unconventional diagnostic tests for Lyme borreliosis: a systematic review

BACKGROUND

Lyme borreliosis (LB) diagnosis currently relies mainly on serological tests and sometimes PCR or culture. However, other biological assays are being developed to try to improve Borrelia-infection diagnosis and/or monitoring.

OBJECTIVES

To analyse available data on these unconventional LB diagnostic assays through a systematic literature review.

METHODS

We searched PubMed and Cochrane Library databases according to the PRISMA-DTA method and the Cochrane Handbook for Systematic Reviews of Interventions. We analysed controlled and uncontrolled studies (published 1983-2018) on biological tests for adults to diagnose LB according to the European Study Group for Lyme Borreliosis or the Infectious Diseases Society of America definitions, or identify strongly suspected LB. Two independent readers evaluated study eligibility and extracted data from relevant study reports; a third reader analysed full texts of papers to resolve disagreements. The quality of each included study was assessed with the QUADAS-2 evaluation scale.

RESULTS

Forty studies were included: two meta-analyses, 25 prospective controlled studies, five prospective uncontrolled studies, six retrospective controlled studies and two case reports. These biological tests assessed can be classified as: (i) proven to be effective at diagnosing LB and already in use (CXCL-13 for neuroborreliosis), but not enough to be standardized; (ii) not yet used routinely, requiring further clinical evaluation (CCL-19, OspA and interferon-α); (iii) uncertain LB diagnostic efficacy because of controversial results and/or poor methodological quality of studies evaluating them (lymphocyte transformation test, interferon-γ, ELISPOT); (iv) unacceptably low sensitivity and/or specificity (CD57⁺ natural killer cells and rapid diagnostic tests); and (v) possible only for research purposes (microscopy and xenodiagnoses).

DISCUSSION

QUADAS-2 quality assessment demonstrated high risk of bias in 25/40 studies and uncertainty regarding applicability for 32/40, showing that in addition to PCR and serology, several other LB diagnostic assays have been developed but their sensitivities and specificities are heterogeneous and/or under-evaluated or unassessed. More studies are warranted to evaluate their performance parameters. The development of active infection biomarkers would greatly advance LB diagnosis and monitoring.

Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies (II). Biological diagnosis, treatment, persistent symptoms after documented or suspected Lyme borreliosis

The serodiagnosis of Lyme borreliosis is based on a two-tier strategy: a screening test using an immunoenzymatic technique (ELISA), followed if positive by a confirmatory test with a western blot technique for its better specificity. Lyme serology has poor sensitivity (30-40%) for erythema migrans and should not be performed. The seroconversion occurs after approximately 6 weeks, with IgG detection (sensitivity and specificity both>90%). Serological follow-up is not recommended as therapeutic success is defined by clinical criteria only. For neuroborreliosis, it is recommended to simultaneously perform ELISA tests in samples of blood and cerebrospinal fluid to test for intrathecal synthesis of Lyme antibodies. Given the continuum between early localized and disseminated borreliosis, and the efficacy of doxycycline for the treatment of neuroborreliosis, doxycycline is preferred as the first-line regimen of erythema migrans (duration, 14 days; alternative: amoxicillin) and neuroborreliosis (duration, 14 days if early, 21 days if late; alternative: ceftriaxone). Treatment of articular manifestations of Lyme borreliosis is based on doxycycline, ceftriaxone, or amoxicillin for 28 days. Patients with persistent symptoms after appropriate treatment of Lyme borreliosis should not be prescribed repeated or prolonged antibacterial treatment. Some patients present with persistent and pleomorphic symptoms after documented or suspected Lyme borreliosis. Another condition is eventually diagnosed in 80% of them.

Increased risk of chikungunya infection in travellers to Thailand during ongoing outbreak in tourist areas: cases imported to Europe and the Middle East, early 2019

We report nine travellers with confirmed chikungunya virus infection, returning from tourist areas of Thailand to Sweden, Switzerland, the United Kingdom, Romania, Israel and France, diagnosed in January and February 2019. These sentinel tourists support the intensification of chikungunya virus circulation in Thailand and highlight the potential for importation to areas at risk of local transmission.

Review of European and American guidelines for the diagnosis of Lyme borreliosis

Lyme disease is a tick-borne bacterial disease with polymorphic clinical manifestations (cutaneous, rheumatological, and neurological). In recent years the issue of the diagnosis of this infection has been highly publicized on the Internet and other media in Europe and America. Some patients and physicians may share the perception that the diagnosis of the infection is not reliable in France. We reviewed current European and American guidelines on Lyme disease and performed a methodological evaluation of all guidelines. We retrieved 16 guidelines from seven countries. Our analysis revealed a global consensus regarding diagnosis at each stage of the infection. All guidelines indicate that the diagnosis is currently based on a two-tier serology at all stages of the infection, except for the early localized dermatological presentation known as Erythema migrans. One text of so-called guidelines has discordant recommendations when compared with the other guidelines, possibly explained by its low quality score. Contrary to the intense debate taking place on the Internet and in the European and American media, our analysis shows that the great majority of medical scientific guidelines with a high quality score, agree on the clinical diagnostic methods of Lyme disease.

Faecal microbiota transplantation shortens the colonisation period and allows re-entry of patients carrying carbapenamase-producing bacteria into medical care facilities

BACKGROUND

Colonisation with carbapenemase-producing Enterobacteriaceae or Acinetobacter (CPE/A) is associated with complex medical care requiring implementation of specific isolation policies and limitation of patient discharge to other medical facilities. Faecal microbiota transplantation (FMT) has been proposed in order to reduce the duration of gut colonisation.

OBJECTIVES

This study investigated whether a dedicated protocol of FMT could reduce the negativation time of CPE/A intestinal carriage in patients whose medical care has been delayed due to such colonisation.

METHOD

A matched case-control retrospective study between patients who received FMT treatment and those who did not among CPE/A-colonised patients addressed for initial clustering at the current institute. The study adjusted two controls per case based on sex, age, bacterial species, and carbapenemase type. The primary outcome was delay in negativation of rectal-swab cultures.

RESULTS

At day 14 post FMT, 8/10 (80%) treated patients were cleared for intestinal CPE/A carriage. In the control group, 2/20 (10%) had spontaneous clearance at day 14 after CPE/A diagnosis. Faecal microbiota transplantation led patients to reduce the delay in decolonisation (median 3 days post FMT for treated patients vs. 50.5 days after the first documentation of digestive carriage for control patients) and discharge from hospital (median 19.5 days post FMT for treated patients vs. 41 for control patients).

CONCLUSION

Faecal microbiota transplantation is a safe and time-saving procedure to discharge CPE/A-colonised patients from the hospital. A standardised protocol, including 5 days of antibiotic treatment, bowel cleansing and systematic indwelling devices removal, should improve protocol effectiveness.

Tick- and flea-borne rickettsioses in Tizi-Ouzou, Algeria: Implications for travel medicine

BACKGROUND

In Algeria, Mediterranean spotted fever (MSF), caused by Rickettsia conorii conorii and transmitted by Rhipicephalus sanguineus, is endemic. However, the documentation of cases is rare due to a lack of laboratory facilities. Our aim was to screen for rickettsioses in patients with fever, rash and a possible inoculation eschar.

MATERIALS AND METHODS

Between 2013 and 2015, patients with a fever and a rash presenting at hospitals in the Tizi-Ouzou region were prospectively included in our study. Sera were screened using Indirect Immunofluorescence Assay (IFA) and qPCR was performed on swab samples from eschars.

RESULTS

One hundred and sixty-six patients were included. For 57 patients, MSF due to R. conorii conorii was diagnosed by serology and qPCR on a swab eschar sample. Three patients were diagnosed with murine typhus, a flea borne rickettsiosis. In addition, two patients had a positive serology in IgM for R. felis. For nine patients, serology for rickettsiosis was positive, but the specific rickettsia involved could not be determined. Nine patients had a severe disease with neurological involvement or multi-organ failure.

CONCLUSION

Clinicians should routinely screen for rickettsioses in patients and travellers presenting with a rash upon return from Algeria. Doxycycline treatment must be given promptly because the prognosis can be severe.