Human herpes virus co-infection is associated with mortality in HIV-negative patients with Pneumocystis jirovecii pneumonia

The purpose of this investigation was to characterize the management and prognosis of severe Pneumocystis jirovecii pneumonia (PJP) in human immunodeficiency virus (HIV)-negative patients. An observational cohort study of HIV-negative adults with PJP documented by bronchoalveolar lavage (BAL) through Gomori-Grocott staining or immunofluorescence, admitted to one intensive care unit (ICU) for acute respiratory failure, was undertaken. From 1990 to 2010, 70 patients (24 females, 46 males) were included, with a mean age of 58.6 ± 18.3 years. The mean Simplified Acute Physiology Score (SAPS)-II was 36.9 ± 20.4. Underlying conditions included hematologic malignancies (n = 21), vasculitis (n = 13), and solid tumors (n = 13). Most patients were receiving systemic corticosteroids (n = 63) and cytotoxic drugs (n = 51). Not a single patient received trimethoprim-sulfamethoxazole as PJP prophylaxis. Endotracheal intubation (ETI) was required in 42 patients (60.0 %), including 38 with acute respiratory distress syndrome (ARDS). In-ICU mortality was 52.9 % overall, reaching 80.9 % and 86.8 %, respectively, for patients who required ETI and for patients with ARDS. In the univariate analysis, in-ICU mortality was associated with SAPS-II (p = 0.0131), ARDS (p < 0.0001), shock (p < 0.0001), and herpes simplex virus (HSV) or cytomegalovirus (CMV) on BAL (p = 0.0031). In the multivariate analysis, only ARDS was associated with in-ICU mortality (odds ratio [OR] 23.4 [4.5-121.9], p < 0.0001). PJP in non-HIV patients remains a serious disease with high in-hospital mortality. Pulmonary co-infection with HSV or CMV may contribute to fatal outcome.

[Recurrent tick-borne fever: a possible diagnosis in patients returning from Senegal]

In Senegal, tick-borne relapsing fever caused by the spirochetes Borrelia crucidurae is the most common cause of fever after malaria in rural areas. However, this is only rarely diagnosed in France, probably because: i) the diagnosis relies on investigations that are not routinely done; ii) even undiagnosed, borreliosis may be cured with empirical antibiotic treatment. We report four observations of tick-borne relapsing fever in patients returning from Senegal: In two patients, the diagnosis relied on the observation of spirochetes in blood smears; in the other two, the diagnosis relied on typical clinico-biological signs, borreliosis serology and exposure. These four cases diagnosed over a four year period in one institution suggest that relapsing fever is not rare in patients returning from West Africa. Patients who return form Senegal with unexplained fever should be investigated with careful examination of blood smears and PCR on blood samples.

[Finding of Strongyloides stercoralis infection, 25 years after leaving the endemic area, upon corticotherapy for ocular trauma]

In the field of ophthalmology, indications for high-dose corticotherapy are various. This paper reports the case of a Caledonian man who presented with intestinal strongyloidiasis, discovered 25 years after he had left the endemic area. A checkup before corticotherapy for traumatic retina edema provided the diagnosis of the infection. The authors emphasize the importance of searching for Strongyloidiasis stercoralis larva before initiating corticotherapy, as it is the main treatment responsible for parasitic dissemination. The most severe form of strongyloidiasis, the disseminated form, has a high mortality rate: 70%-90%. The definitive diagnostic test is enhanced larva recovery, which should be proposed to every patient returning from endemic area, people with precarious hygiene or with high eosinophilia or intestinal symptoms of chronic infection. Delay in diagnosing strongyloidiasis frequently results in death, despite vigorous treatment.

Comparison of epidemiological, clinical, and biological features of invasive aspergillosis in neutropenic and nonneutropenic patients: a 6-year survey

BACKGROUND

Invasive aspergillosis is an opportunistic infection that occurs mainly among patients with prolonged neutropenia. Few data are available on invasive aspergillosis in nonneutropenic patients.

METHODS

The aim of this survey was to compare neutropenic and nonneutropenic patients who had received a diagnosis of invasive aspergillosis at our institution during a 6-year period.

RESULTS

Among the 88 cases of invasive aspergillosis analyzed here, 12 were histologically proven, 52 were probable, and 24 were possible. Forty-seven percent of cases were diagnosed in the intensive care unit, and 40% were diagnosed in hematology units. Neutropenia was a risk factor for 52 patients (59%), most of whom had hematological or solid malignancies. Among the 36 nonneutropenic patients (41%), the main underlying conditions were steroid-treated chronic obstructive pulmonary disease, asthma, rheumatoid arthritis, giant-cell arteritis, and microvascular disorders; 10 patients were recipients of solid-organ transplants, and 1 patient was seropositive for human immunodeficiency virus. The distribution of proven and probable invasive aspergillosis was similar for neutropenic and nonneutropenic patients. The mortality rate was 71.5% overall and was significantly higher among nonneutropenic patients than among neutropenic patients (89% vs. 60%; P<.05). Compared with neutropenic patients, nonneutropenic patients were significantly less likely to have symptoms of invasive aspergillosis and more likely to have frequent intercurrent pneumonia due to another microorganism. The sensitivity of mycological examination of bronchoalveolar lavage fluid specimens was higher for nonneutropenic patients than for neutropenic patients (85% vs. 58%; P<.05), whereas the sensitivity of antigenemia was the same for the 2 populations (65% vs. 64%). Findings on thoracic computed tomographs were similar, except that segmental areas of consolidation occurred more frequently among neutropenic patients.

CONCLUSION

This survey at a whole institution underlines the high number of cases of invasive aspergillosis among nonneutropenic patients, with an overall mortality rate that was significantly higher than that for neutropenic patients.

Infections à cryptocoque chez des patients non VIH. À propos de quatre cas et revue de la littérature

BACKGROUND

Cryptococcal infections are frequent in HIV-infected patients and are regularly looked after. This infection may occur in others immunosuppressives situations and, in those cases, diagnosis is often delayed.

METHODS

We report four cases of cryptococcal infections in patients whose immunosuppression isn't related with HIV infection but due to chronic lymphocytic leukemia, giant cell temporal arteritis, gastric neoplasm and lupus. Diagnosis, prognostic and treatment are detailed.

RESULTS

Four patients aged from 25 to 76 presented a cryptococcal infection (three meningitis). A woman died at the admission. Another died seven years later. The two others are still alive under treatment. When infected, all patients were immunodeficiency.

CONCLUSION

Cryptococcal infection may occur in patients non-HIV-infected patients. Early detection is needed to improve prognostic.

[Post-inflammatory cutis laxa. A case report]

Cutis laxa (CL) is a rare disorder in which the skin hangs in loose fields, so that affected individuals appear to be prematurely aged. The changes are more evident when effect the face with a prematurely-aged appearance. The acute form follows an inflammatory skin lesions. Its aetiology is not well known. We report a case of a head acute CL of a 17 years patient, secondary to a generalized skin eruption. The prematurely-aged appearance concern especially forehead, ear lobes and nasolabial folds. A two stages surgical treatment has associated: a forehead lifting associated to a Coleman lipofilling and an ear lobe reduction, a secondary Coleman lipofilling of the nasolabial folds. The skin biopsy confirm the diagnosis. The correction is stable and satisfactory after one year. The confrontation of our findings to those previously described confirm complexity of diagnosis and histological observations of this rare disorder.

Breast feeding after reduction mammaplasty performed during adolescence

Reduction mammaplasty (RM) can be performed during adolescence if the functional capacity of the breast is preserved. Future breast feeding must be carefully considered in the therapeutic decision making process.

PURPOSE OF THE STUDY

Breast feeding after reduction mammaplasty performed during adolescence was assessed to determine surgical factors influencing outcome and patient reception of information concerning breast feeding.

METHODS

A questionnaire was sent to 109 women who had undergone reduction mammaplasty between 1981 and 1997 when they were 15-17 years old to ascertain their reasons for having surgery, their satisfaction, and their attitude towards breast feeding.

RESULTS

Sixty-five questionnaires (60%) could be analyzed. Mean delay since surgery was 8.1 years. Seventeen women (26%) had delivered 25 infants (mean 1.5). Mean delay after surgery to first delivery was 7.68 years. Five women (29%) nursed their first infant for a mean 11.3 days. None of the women interrupted breast feeding for a reason related to a nipple anomaly or difficult sucking. Twelve women (71%) did not nurse their first infant, because of the prior breast surgery for six of them. Among the 48 nulliparous women, 24 (50%) stated they would nurse their future infant. Although information on breast feeding was systematically delivered, 41 women (63%) stated they had not been informed. There was no statistical relationship between breast feeding and degree of satisfaction, patient-assessed scar quality, or nipple disorders.

CONCLUSION

Adolescents who undergo reduction mammaplasty can nurse their future infants with a complication rate similar to that in the general population. Special attention must be given to delivery of information on breast feeding.

[Juvenile breast hypertrophy: analysis of long-term results of reductive mammoplasty]

Reduction mammaplasty has now become routine surgery with good results in middle-aged women. However the scars it leaves, its psychological and functional (breastfeeding) impact could limited its indications in teenage girls.

AIM

The purpose of our study was to report the long-term results of reduction mammaplasty in teenage girls and to assess their consequences.

MATERIAL AND METHODS

We conducted a retrospective study of 65 reduction mammaplasty carried out between 1981 and 1997 in 15 to 17 years old girls. The study was based on data in their medical records and answers to a questionnaire which was sent to each patient.

RESULTS

Average followup was 8.1 years. The reduction technique with superior pedicle were mainly used. Average breast tissue excised was 1050 g. Minor complications occurred in three cases. Eleven revisions had to be carried out with 1.6 years on average after primary surgery. The psychological and functional complaints observed preoperatively disappeared in more than 90% of the cases. In over 80% of the cases the patients were pleased or very pleased with the shape, the volume kept and the symmetry. Scars were well accepted in 83% of the cases. Seventeen women were given birth to 25 children. Five of whom breast-fed their babies, while six refused because of their breast surgery history. Although information about breast-feeding after such surgery is systematically given, 41 women claimed they had not received it.

CONCLUSION

Reduction mammaplasty is reliable in teenage girls. Patients are generally satisfied and the remaining scar is well accepted. Breast-feeding is possible after this surgery and information on that point ought to be better developed.

[Tuberous breast syndrome. Report on a series of 22 operated patients]

The tuberous breast syndrome is a rare unilateral or bilateral breast malformation presenting at the age of mammary development. It requires surgical correction, depending on the severity of the clinical expression, because of its inaesthetic appearance. We report a series of 22 patients (35 breasts) treated and followed up in the plastic and reconstructive surgery department of Rennes over a period of nearly ten years. The average age was 18 +/- 3.2 years (range: 15-26 years old). Long-term results were assessed by the surgical team and the patients on the basis of objective and subjective criteria with an average follow-up of 36 months (12 to 116 months). In our opinion, surgical correction should be proposed after puberty with, whenever possible, section of the basal fibrous ring and glandular plasty via a periareolar incision. The use of mammary implant alone or in combination with breast tissue remodelling must be reserved for hypoplastic cases only.

Post-traumatic course complicated by cutaneous infection with Absidia corymbifera

Cutaneous mucormycosis is a rare but serious infection in trauma patients. Reported here is the case of a young patient with cutaneous mucormycosis due to Absidia corymbifera probably caused by a soil-contaminated wound. Despite daily surgical debridement and amphotericin B therapy, cure could be achieved only by amputation of the lower limb.

Prophylactic use of itraconazole for the prevention of invasive pulmonary aspergillosis in high risk neutropenic patients

Invasive pulmonary aspergillosis (IPA) is an increasing cause of morbidity and mortality in patients with hematologic malignancies. A major program of construction work close to our unit prompted us to evaluate the efficacy of itraconazole prophylaxis in preventing IPA in these patients. During September 1994 to December 1995, 77 patients undergoing 96 neutropenic episodes (mean duration, 19.3 days +/- 9.1) received itraconazole as antifungal prophylaxis. All patients were treated in laminar air flow rooms. Itraconazole was administered at a loading dose of 600mg/d, (day 1 to day 3) and 400mg/d on the following days, in 87 instances. In the remaining episodes, the daily dose was 200 or 400mg. Oral doses were adjusted to reach a plasma itraconazole level (PIL) above 1000ng/l. In cases of inadequate PIL or poor oral intake, IV AmphoB was started at a 20 mg daily dose. Five cases of IPA (proven n = 2, probable n = 3) were observed. This represents an incidence of 5.2% of the total number of episodes. One out of 67 (2%) treatment episodes with adequate PIL were associated with IPA as compared to 4 of 29 (14%) episodes with inadequate PIL, (p < 0.02). AmphoB was added in 28 cases because of low PIL (n = 25), and/or antibiotic-resistant fever persistent pulmonary infiltrate (n = 8). These results need to be interpreted with caution, because of the absence of randomization or a control group. The efficacy of Itraconazole in neutropenic patients with high risk IPA has to be confirmed on larger and prospective studies.

Use of DNA fingerprinting and biotyping methods to study a Candida albicans outbreak in a neonatal intensive care unit

During a 15-day period, 7 premature infants hospitalized in a neonatal intensive care unit presented with sepsis caused by Candida albicans. The local environment and hands of all 54 persons involved in the intensive care unit were examined for the presence of this organism. Five techniques were used in the analysis of the isolates recovered from blood cultures of the children, the hands of personnel and 10 control isolates. The methods used were serotype determination, genetic fingerprinting, morphotyping, resistotyping and killer yeast typing. Morphotyping and genetic fingerprinting proved to be the most discriminatory techniques, and only combined analysis of the results obtained with these various methods allowed the source of the outbreak to be identified. An isolate from the hands of a healthy staff member and isolates from infected children all belonged to the same strain.

[Observation in France of Simulium erythrocephalum De Geer, 1776 as an agent of human simuliidosis]

Second observation of this black-fly in human simuliidosis. The country is the department of Vaucluse.

[Human simuliidosis in France: antiquity, anthropophilic species]

The problem of the human Simuliidosis (caused by black flies) is reviewed for the France: important and, perhaps, relatively recent increase from the known human attacks by black flies. Countries and anthropophilic species are cited.