Pharmacokinetic Interaction between Rifampicin and Clindamycin in Staphylococcal Osteoarticular Infections

The oral combination of clindamycin and rifampicin is relevant for the treatment of staphylococcal osteoarticular infections (SOAI). However, rifampicin induces CYP3A4, suggesting a pharmacokinetic (PK) interaction with clindamycin with unknown PK/pharmacodynamic (PD) consequences.

OBJECTIVES

To quantify clindamycin PK/PD markers before and during rifampicin co-administration in OAI.

METHODS

Patients with SOAI were included (NCT02782078). After an initial intravenous antistaphylococcal treatment, oral therapy was started with clindamycin (600 or 750 mg tid), followed by the addition of rifampicin 36 hours after. Population PK analysis was performed using the SAEM algorithm. PKPD markers were compared with and without rifampicin co-administration, each patient being his own control.

RESULTS

In 19 patients, Clindamycin Median (min-max) through concentrations were 2.7 (0.3-8.9) and <0.05 (<0.05-0.3) mg/L, before and during rifampicin administration, respectively. Rifampicin co-administration increased clindamycin clearance by a factor 16 and reduced the AUC_0-8h /MIC by a factor 15 (p<0.005). We simulated clindamycin plasma concentration for 1000 individuals, without and with rifampicin. Against a susceptible S. aureus strain with a clindamycin MIC of 0.0625 mg/L, more than 80% of individuals would reach all the proposed PKPD targets without co-administration of rifampicin, even with a low clindamycin dose. For the same strain, when rifampicin was co-administered, the probability to reach clindamycin PKPD targets dropped to 1% to have a %fT_>MIC = 100% and to 6% to achieve an AUC_0-24/MIC > 60, even with high dose of clindamycin.

CONCLUSION

Rifampicin co-administration with clindamycin has high impact on clindamycin exposure and PKPD targets in SOAI, which could result in clinical failures, even for a fully susceptible strain.

Evolution of fluoroquinolone-resistant Escherichia coli in the gut after ciprofloxacin treatment

BACKGROUND

Three healthy volunteers carried similar quinolone-resistant E. coli (QREC) (pulsed field gel electrophoresis profiles) in their gut before and after 14 days ciprofloxacin treatment. Given the intensity of the selective pressure and the mutagenic properties of quinolones, we determined whether these strains had evolved at the phenotypic and/or genomic levels.

MATERIAL AND METHODS

Commensal QREC from before day-0 (D0), and a month after 14 days of ciprofloxacin (D42) were compared in 3 volunteers. Growth experiments were performed; acetate levels, mutation frequencies, quinolone MICs and antibiotic tolerance were measured at D0 and D42. Genomes were sequenced and single nucleotide polymorphisms (SNPs) between D0 and D42 were analyzed using DiscoSNP and breseq methods. Cytoplasmic proteins were extracted, HPLC performed and proteins identified using X!tandem software; abundances were measured by mass spectrometry using the Spectral Counting (SC) and eXtraction Ion Chromatograms (XIC) integration methods.

RESULTS

No difference was found in MICs, growth characteristics, acetate concentrations, mutation frequencies, tolerance profiles, phylogroups, O-and H-types, fimH alleles and sequence types between D0 and D42. No SNP variation was evidenced between D0 and D42 isolates for 2/3 subjects; 2 SNP variations were evidenced in one. At the protein level, very few significant protein abundance differences were identified between D0 and D42.

CONCLUSION

No fitness, tolerance, metabolic or genomic evolution of commensal QREC was observed overtime, despite massive exposure to ciprofloxacin in the gut. The three strains behaved as if they had been unaffected by ciprofloxacin, suggesting that gut may act as a sanctuary where bacteria would be protected from the effect of antibiotics and survive without any detrimental effect of stress.

Mortality in Escherichia coli bloodstream infections: antibiotic resistance still does not make it

BACKGROUND

Escherichia coli bloodstream infections (BSIs) account for high mortality rates (5%-30%). Determinants of death are unclear, especially since the emergence of ESBL producers.

OBJECTIVES

To determine the relative weight of host characteristics, bacterial virulence and antibiotic resistance in the outcome of patients suffering from E. coli BSI.

METHODS

All consecutive patients suffering from E. coli BSI in seven teaching hospitals around Paris were prospectively included for 10 months. E. coli isolates were sequenced using Illumina NextSeq technology to determine the phylogroup, ST/ST complex (STc), virulence and antimicrobial resistance gene content. Risk factors associated with death at discharge or Day 28 were determined.

RESULTS

Overall, 545 patients (mean ± SD age 68.5 ± 16.5 years; 52.5% male) were included. Mean Charlson comorbidity index (CCI) was 5.6 (± 3.1); 19.6% and 12.8% presented with sepsis and septic shock, respectively. Portals of entry were mainly urinary (51.9%), digestive (41.9%) and pulmonary (3.5%); 98/545 isolates (18%) were third-generation cephalosporin resistant (3GC-R), including 86 ESBL producers. In-hospital death (or at Day 28) was 52/545 (9.5%). Factors independently associated with death were a pulmonary portal of entry [adjusted OR (aOR) 6.54, 95% CI 2.23-19.2, P = 0.0006], the iha_17 virulence gene (aOR 4.41, 95% CI 1.23-15.74, P = 0.022), the STc88 (aOR 3.62, 95% CI 1.30-10.09, P = 0.014), healthcare-associated infections (aOR 1.98, 95% CI 1.04-3.76, P = 0.036) and high CCI (aOR 1.14, 95% CI 1.04-1.26, P = 0.006), but not ESBL/3GC-R.

CONCLUSIONS

Host factors, portal of entry and bacterial characteristics remain major determinants associated with mortality in E. coli BSIs. Despite a high prevalence of ESBL producers, antibiotic resistance did not impact mortality. (ClinicalTrials.gov identifier: NCT02890901.).

Dimercaptosuccinic acid in combination with carbapenems against isogenic strains of Escherichia coli producing or not producing a metallo-β-lactamase in vitro and in murine peritonitis

BACKGROUND

Carbapenemase-producing Enterobacterales represent a major therapeutic challenge. MBLs, requiring zinc at their catalytic site, could be inhibited by meso-dimercaptosuccinic acid (DMSA), a heavy metal chelator already widely used for treating lead intoxication.

OBJECTIVES

To evaluate the activity of carbapenems alone or combined with DMSA against MBL-producing Escherichia coli in a severe murine peritonitis model.

METHODS

Isogenic strains of wild-type E. coli CFT073 producing the MBLs NDM-1, VIM-2 and IMP-1, and the control serine carbapenemases OXA-48 and KPC-3 were constructed. MIC determinations and time-kill assays were performed for imipenem, meropenem and ertapenem alone or in combination with DMSA. Infected mice were treated intraperitoneally for 24 h with imipenem, DMSA or their combination. Bacterial counts in peritoneal fluid and spleen were assessed at 24 h.

RESULTS

DMSA in combination with each carbapenem caused a significant decrease in the MICs for all MBL-producing strains, in a concentration-dependent manner, but did not provide benefit against non-MBL strains. In mice infected with the NDM-1-producing strain, the combination of imipenem and DMSA significantly reduced bacterial counts in peritoneal fluid (P = 0.0006) and spleen (P < 0.0001), as compared with imipenem alone, with no benefit against the KPC-3-producing and CFT073 strains. DMSA concentrations in plasma of mice were comparable to those obtained in humans with a standard oral dose.

CONCLUSIONS

DMSA restores the activity of carbapenems against MBL-producing strains, and its combination with carbapenems appears to be a promising strategy for the treatment of NDM-producing E. coli infections.

[Characteristics of patients admitted from emergency units in 18 internal medicine departments and organisation of these departments: A cross sectional study from SNFMI (SiFMI study group) in 2015]

INTRODUCTION

Patients admitted from emergency units represent a large portion of the population in internal medicine departments. The aim of this study is to identify characteristics of patients and organization of these departments.

METHODS

Between June 29th and July 26th 2015, voluntary internal medicine departments from the SiFMI group prospectively filled anonymized internet forms to collect data of each patients admitted in their ward from emergency units, during seven consecutive days.

RESULTS

Three hundred and sixty-five patients from emergency departments were admitted in 18 internal medicine inpatients departments, totalling 1100 beds and 33,530 annual stays, 56% of them for emergency units inpatients. Mean age was 68 years, 54% were women, mean Charlson score was 2.6 and 44% of the patients took at least three drugs. Main causes of hospitalization were infectious (29%) and neurological (17%) diseases. Mean length of stay was 9.2 days. The medical team was composed by a median value of 4,5 [2,75-6,25] senior full-time equivalents, 86% were internists. Each department except one received residents, two third of them were from general medicine.

CONCLUSION

This study highlights a high organizational variability among internal medicine departments and patients, and sets internal medicine as a specialty with a great capacity to achieve an integrative/comprehensive management of patients and to offer a comprehensive basis for physicians in training.

Activity of fosfomycin alone or combined with temocillin in vitro and in a murine model of peritonitis due to KPC-3- or OXA-48-producing Escherichia coli

Background

Alternative therapeutic regimens are urgently needed against carbapenemase-producing Enterobacteriaceae. Fosfomycin often remains active against KPC and OXA-48 producers, but emergence of resistance is a major limitation. Our aim was to determine whether the association of temocillin with fosfomycin might be useful to treat KPC- or OXA-48-producing Escherichia coli infections.

Methods

Isogenic derivatives of E. coli CFT073 with blaKPC-3- or blaOXA-48-harbouring plasmids (named CFT073-KPC-3 and CFT073-OXA-48, respectively) were used. The addition of temocillin to fosfomycin was tested using the chequerboard method and time-kill curves as well as in a fatal peritonitis murine model. Mice were treated for 24 h with fosfomycin alone or in combination with temocillin. Bacterial loads, before and after treatment, were determined in the peritoneal fluid and fosfomycin-resistant mutants were detected.

Results

Temocillin MICs were 8, 32 and 256 mg/L for CFT073 (WT), CFT073-KPC-3 and CFT073-OXA-48, respectively. Fosfomycin MIC was 0.5 mg/L for all strains. The chequerboard experiments demonstrated synergy for all three strains. In time-kill curves, combining temocillin with fosfomycin was synergistic, bactericidal and prevented emergence of resistance for CFT073-pTOPO and CFT073-KPC-3, but not CFT073-OXA-48. In vivo, for the three strains, bacterial counts were lower in peritoneal fluid with the combination compared with fosfomycin alone (P < 0.001) and inhibited growth of resistant mutants in all cases.

Conclusions

The combination of fosfomycin and temocillin demonstrated a benefit in vitro and in vivo against E. coli strains producing KPC-3 or OXA-48-type carbapenemases. This combination prevented the emergence of fosfomycin resistance and proved to be more bactericidal than fosfomycin alone.

The inoculum effect of Escherichia coli expressing mcr-1 or not on colistin activity in a murine model of peritonitis

OBJECTIVES

Colistin often remains the last resort antibiotic active against carbapenemase-producing Enterobacteriaceae. However, while in vitro inoculum effect has been reported, therapeutic relevance of this phenomenon remains questioned.

METHODS

Ten E. coli strains were used that included the wild-type CFT073 and its transconjugant CFT073-MCR-1 and eight susceptible clinical isolates. Mice with peritonitis were treated for 24 h with colistin sulfate. Bacterial loads were determined in peritoneal fluid (PF) and spleen and colistin-resistant mutants were detected.

RESULTS

MICs of colistin against the eight susceptible clinical strains and CFT073 ranged from 0.125 to 0.5 mg/L with an inoculum of 10⁵ CFU/mL and from 2 to 4 mg/L with a 10⁷ CFU/mL inoculum; 5/9 strains with an MIC of 4 mg/L were considered resistant according to EUCAST breakpoint (resistance, > 2 mg/L). When the bacterial load of wild-type CFT073 inoculated in mice increased from 10⁷ to 10⁸ CFU: i) mean log₁₀ CFU reduction generated by colistin in PF and spleen decreased from 5.8/mL and 3.1/g, respectively, (p < 0.01) to 0.9/mL and 0.8/g, respectively (NS); ii) mice survival rate decreased from 15/15 (100%) to 6/15 (40%) (p = 0.017); and iii) proportion of mice with selection of colistin-resistant mutants increased from 4/15 to 15/15 (p < 0.01). These results were comparable to those obtained when peritonitis was produced with a 10⁷ CFU bacterial load of E. coli CFT073 expressing mcr-1, for which the mean log₁₀ CFU reductions were 3.5/mL and 0.6/g in PF and spleen, respectively (NS), and survival rate was 8/15 (53%) (p < 0.01 versus survival of mice infected with wild-type CFT073).

CONCLUSIONS

Phenotypic colistin resistance in wild-type E. coli due to an increase in inoculum size had a therapeutic impact in mice with peritonitis that was comparable to that observed when the mcr-1 gene was expressed.

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.

[Insights on the management of Lyme disease]

Lyme disease is currently a hot topic in France due to a high incidence in some areas. Its clinical polymorphism can lead to misdiagnosis on one hand and to unjustified treatment on the other hand. Clinical symptoms vary considerably according to involved organs (skin, central and/or peripheral nervous system, joints, heart, eyes) and may be limited to or associated with general non-specific signs. Biological exams must be guided by clinical symptoms to help diagnosis and treatment decision according to clinical history, presentation, time of onset and duration of symptoms. However, to date, no serologic test can discriminate between past and active disease. The role of the internist is two-fold: make a diagnosis when faced with general or focal symptoms and avoid inappropriate attribution to Lyme disease of symptoms related to alternate diagnoses.

[Influenzae and pneumococcal vaccination rate in an internal medicine ward]

INTRODUCTION

Vaccination against influenza virus and Streptococcus pneumoniae is a global health priority and authorities, on the basis of recent publications, have recently updated French recommendations. The aim of this study was to describe the influenzae and pneumococcal vaccination's rate in an internal medicine ward.

MATERIAL AND METHODS

All patients consecutively hospitalized during a 10 week-period in an internal medicine ward were included. The reasons for non-vaccination and the impact of an educational program for corrective measures were reported.

RESULTS

Overall, 198 consecutive patients were included; 93 (47%) were immunocompromised; 142 (71.2%) had an indication for pneumococcal vaccination and 171 (86.4%) for influenza vaccination but only 16.2% and 55% of them were vaccinated against these microorganisms, respectively. Prior pneumococcal vaccination was more frequently observed in immunocompromised patients than in non-immunocompromised patients (21.1 versus 6.4%; P=0.029), but no significant difference was observed for influenza vaccine. Corrective measures were initiated in 46 patients (39%), non-immunized against S. pneumoniae.

CONCLUSION

These results underline the very low prevalence of pneumococcal vaccination rate in at-risk hospitalized patients, as compared with influenza, despite recent recommendations.

Medical complications following splenectomy

Splenectomy is attended by medical complications, principally infectious and thromboembolic; the frequency of complications varies with the conditions that led to splenectomy (hematologic splenectomy, trauma, presence of portal hypertension). Most infectious complications are caused by encapsulated bacteria (Meningococcus, Pneumococcus, Hemophilus). These occur mainly in children and somewhat less commonly in adults within the first two years following splenectomy. Post-splenectomy infections are potentially severe with overwhelming post-splenectomy infection (OPSI) and this justifies preventive measures (prophylactic antibiotics, appropriate immunizations, patient education) and demands prompt antibiotic management with third-generation cephalosporins for any post-splenectomy fever. Thromboembolic complications can involve both the caval system (deep-vein thrombophlebitis, pulmonary embolism) and the portal system. Portal vein thrombosis occurs more commonly in patients with myeloproliferative disease and cirrhosis. No thromboembolic prophylaxis is recommended apart from perioperative low molecular weight heparin. However, some authors choose to prescribe a short course of anti-platelet medication if the post-splenectomy patient develops significant thrombocytosis. Thrombosis of the portal or caval venous system requires prolonged warfarin anticoagulation for 3 to 6 months. Finally, some studies have suggested an increase in the long-term incidence of cancer in splenectomized patients.

Infections Revealing Complement Deficiency in Adults: A French Nationwide Study Enrolling 41 Patients

Complement system is a part of innate immunity, its main function is to protect human from bacterial infection. As genetic disorders, complement deficiencies are often diagnosed in pediatric population. However, complement deficiencies can also be revealed in adults but have been poorly investigated. Herein, we describe a case series of infections revealing complement deficiency in adults to study clinical spectrum and management of complement deficiencies.A nationwide retrospective study was conducted in French university and general hospitals in departments of internal medicine, infectious diseases enrolling patients older than 15 years old who had presented at least one infection leading to a complement deficiency diagnosis.Forty-one patients included between 2002 and 2015 in 19 different departments were enrolled in this study. The male-to-female ratio was 1.3 and the mean age at diagnosis was 28 ± 14 (15-67) years. The main clinical feature was Neisseria meningitidis meningitis 75% (n = 31/41) often involving rare serotype: Y (n = 9) and W 135 (n = 7). The main complement deficiency observed was the common final pathway deficiency 83% (n = 34/41). Half of the cohort displayed severe sepsis or septic shock at diagnosis (n = 22/41) but no patient died. No patient had family history of complement deficiency. The mean follow-up was 1.15 ± 1.95 (0.1-10) years. Half of the patients had already suffered from at least one infection before diagnosis of complement deficiency: meningitis (n = 13), pneumonia (n = 4), fulminans purpura (n = 1), or recurrent otitis (n = 1). Near one-third (n = 10/39) had received prophylactic antibiotics (cotrimoxazole or penicillin) after diagnosis of complement deficiency. The vaccination coverage rate, at the end of the follow-up, for N meningitidis, Streptococcus pneumonia, and Haemophilius influenzae were, respectively, 90% (n = 33/37), 47% (n = 17/36), and 35% (n = 14/34).This large study emphasizes that complement deficiencies can be revealed in adults by infectious episodes. Most of them were meningococcal infections revealing common final pathway deficiency. To avoid undiagnosis or late diagnosis, adult displaying first episode of N meningitidis infection should be tested for complement deficiency.

Activity of temocillin in a lethal murine model of infection of intra-abdominal origin due to KPC-producing Escherichia coli

OBJECTIVES

Temocillin is a 6-α-methoxy derivative of ticarcillin that shows in vitro activity against Enterobacteriaceae producing Klebsiella pneumoniae carbapenemase (KPC). Our objective was to assess in vivo temocillin activity against KPC-producing Escherichia coli.

METHODS

Isogenic derivatives of the WT E. coli CFT073 producing KPC-2, KPC-3 or OXA-48 were constructed. An experimental murine model of intra-abdominal infection with sepsis was used. Mice were treated subcutaneously with temocillin 200 mg/kg every 2 h for 24 h, reproducing the duration of time that the free serum concentration of temocillin exceeded the MIC in humans with a regimen of 2 g every 12 h or 2 g every 8 h. Blood, peritoneal fluid (PF) and spleen were collected; 24 h survival and sterility rates were assessed.

RESULTS

Temocillin MICs were 8, 16, 32, and 256 mg/L for the susceptible strain and KPC-2-, KPC-3-, and OXA-48-producing strains, respectively. In mice treated with temocillin, significant bacterial reduction was obtained in PF, blood, and spleen for the susceptible strain and KPC-2- and KPC-3-producing strains (P < 0.001) but not for the OXA-48-producing strain. Sterility rates in PF were 53%, 10%, 0% and 0% (P < 0.001) and sterility rates in blood were 77%, 40%, 3% and 0% (P < 0.001), while survival rates were 97%, 97%, 57%, 0% (P < 0.001) for mice infected with the susceptible strain and KPC-2-, KPC-3- and OXA-48-producing strains, respectively.

CONCLUSIONS

In a lethal-infection model with bacteraemia from intra-abdominal origin, temocillin retained significant activity in PF, blood and spleen and prevented death in mice by effectively working against KPC-producing E. coli with temocillin MICs ≤16 mg/L.

[Pyogenic brain abscesses in adults]

Pyogenic brain abscesses (BA) are rare and their diagnosis may be difficult because of the absence of specific clinical or biological signs. However, the use of diffusion-weighted brain MRI sequences has modified the management of BA, as they are highly sensitive and specific to differentiate pyogenic brain abscesses from necrotic tumors, which are the most frequent differential diagnosis in case of ring-enhancing lesions on CT scan. This new tool allows for a rapid diagnosis and should be followed by a CT-guided aspiration of BA. This safe procedure should be performed if possible before starting antibiotics in order to optimize microbiological diagnosis. Recent epidemiological changes include an increase in the numbers of immunocompromised patients and a decrease in the traditional causes of BA (direct inoculation, ear nose and throat infections, etc.). In consequence, a wider range of bacterial species may be involved, making it all the more necessary to obtain a microbiological diagnosis. Many uncertainties remain in terms of the duration of antibiotic treatment, the optimal radiological follow-up and the place for associated treatments such as corticosteroids and anticonvulsive therapy. BA remain severe infections with high mortality and morbidity rates; the factor most regularly associated with a poor prognosis is the patients neurological status at diagnosis.

[Starvation ketosis in a breastfeeding woman]

INTRODUCTION

Bovine ketosis is a rare cause of metabolic acidosis. It is a starvation ketosis that appears in lactating woman.

CASE REPORT

A 29-year-old woman had a previous gastric surgery one month ago while breastfeeding her 6-month child. She presented to emergency with dyspnea, fatigue, weight loss and anorexia. The explorations revealed a serious metabolic acidosis with a high anion gap, for which all other causes have been eliminated.

CONCLUSION

A restrictive diet in lactating patients is a major risk of ketosis or bovine ketosis. Medico-surgical treatment of obesity during lactation seems unreasonable. Breastfeeding should be systematically sought before a medical and surgical management of obesity. With the spread of bariatric surgery, starvation ketosis is a cause of metabolic acidosis not to ignore.

[Investigation and management of genito-urinary tuberculosis]

Genito-urinary tuberculosis is the fourth most common manifestation of the disease, but it is often underestimated by clinicians because of few and non-specific symptoms and insidious disease course. The most common urinary findings are multiple ureteral stenosis. The most common genital involvement is an epididymal nodule for men and a chronic salpingitis for women. The definite diagnosis of genito-urinary tuberculosis is obtained on the basis of culture studies. Due to the paucibacillary nature of the disease, especially of genital location in woman, a probable or presumptive diagnosis is frequently considered with several parameters including radiological imaging (abdominal CT-scan, pelvic ultrasound, pelvic MRI). Endoscopic and surgical procedures are frequently required to obtain specimens for histopathologic and bacteriological studies. Medical treatment is the method of choice, with a combination of four drugs, namely isoniazid, rifampicin, ethambutol and pyrazinamide, followed by a two-drug regimen, for a total of six month duration. Surgery might be indicated in complicated genito-urinary tuberculosis (decreased renal function, infertility, urologic complaints).

[Resistance to fluoroquinolones in 2013: what are the consequences in internal medicine?]

Because of their important qualities, fluoroquinolones are amongst the most prescribed antibiotics in the world. The corollary of this success is the rapid increase in resistance to fluoroquinolones, responsible for treatment failures. Moreover, fluoroquinolone-resistance is often accompanied by resistance to other classes of antibiotics. Currently, significant levels of resistance are found both in hospitals and in community settings, severely limiting possibilities for empirical use of fluoroquinolones. A major mechanism explaining the rapid emergence of resistance to fluoroquinolones is their specific impact on human microbiota and the selection of resistant strains in the microbiota, which seems to be an unavoidable ecological side effect. In order to preserve the efficiency of this important class of antibiotics, limiting their use and respecting good practice recommendations are essential.

[Agranulocytosis and vasculitis in a cocaine addict: levamisole, the hidden culprit]

INTRODUCTION

Adulterants are compounds added to street drugs to increase profits for the seller. Levamisole, a veterinary antihelminthic agent, has become the most common adulterant of cocaine. The prevalence of levamisole in samples of cocaine is increasing. Levamisole can lead to neutropenia and to a dramatic vasculopathy and even vasculitis of small and medium-size blood vessels.

CASE REPORT

We here reported the first French case of levamisole related toxicity, due to cocaine use in a 50-year-old man, revealed by fever and agranulocytosis, high titters of antineutrophil cytoplasmic antibodies (ANCA), anticoagulant and positive Coombs tests. Outcome was slowly favorable with exposition withdrawal.

CONCLUSION

Clinicians should be aware that agranulocytosis or vasculitis or vasculopathy could be related to levamisole toxicity in individuals who use cocaine.

[Intermittent prolonged fever triggered by efforts]

INTRODUCTION

Fever of unknown origin is a common reason for care in internal medicine. The wide variety of possible etiologies makes it difficult to standardize the diagnostic work-up that has to be primarily guided by the interview and physical examination.

CASE REPORT

We report a case of prolonged fever having as main characteristics to be intermittent and triggered by efforts. The diagnosis of cerebrospinal fluid shunt infection with Propionibacterium acnes was finally made. In reaching this conclusion, many tests were needed, including renal explorations with biopsy showing an aspect of shunt nephritis.

CONCLUSION

Prolonged fever of unknown origin in a patient having prosthetic material should raise the suspicion of prosthesis infection (especially if the fever is associated with efforts).