Ruling out nosocomial transmission of Cryptosporidium in a renal transplantation unit: case report

Background

Cryptosporidium spp. is a ubiquitous parasite affecting humans as well as domestic and wild vertebrates, causing diarrhea in both immunocompetent and immunocompromised hosts worldwide. Its transmission occurs primarily by the fecal-oral route. In humans, C. parvum and C. hominis are the most prevalent species, whereas immunocompetent and immunocompromised individuals can also be infected by other zoonotic species. Renal transplant patients are prone to develop cryptosporidiosis, which can induce severe and life-threatening diarrhea.

Case presentation

We report here a series of nearly concomitant cases of acute symptomatic cryptosporidiosis in three renal transplant patients attending the Strasbourg University Hospital Nephrology Unit. The clinical presentation was persistent diarrhea and acute renal failure. The diagnosis was confirmed by microscopic stool examination using a modified Ziehl-Neelsen staining method and species identification by molecular tools. All patients were treated with nitazoxanide and recovered from diarrhea after 14 days of therapy.

Conclusion

Genotypic species identification was not consistent with an epidemic context, thus underlining the need for genotyping to monitor at risk patients.

Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage

BACKGROUND

The long-term effects of uterine artery embolization for the control of postpartum haemorrhage on menses, fertility and future pregnancy evolution have not been assessed.

METHODS

Between November 1993 and July 1999, 31 women with obstetric haemorrhage underwent arterial embolization. Four patients underwent a hysterectomy. Gynaecological information on 25 of the 27 patients who did not undergo hysterectomy was obtained by interview.

RESULTS

All women had a return of normal menses. Nine of the 25 patients desired subsequent pregnancy and five patients became pregnant with normal delay of conception. Moreover, two other patients who did not plan another pregnancy became pregnant. A total of 10 pregnancies was studied, four ended during the first trimester. For the six others, the maternal evolution of the pregnancy was uneventful until term. No case of pre-eclampsia was observed. The ultrasonographic examinations revealed normal fetal growth and umbilical and uterine Doppler studies showed no anomaly. No repetition of obstetric haemorrhage was observed. All full-term, newborns were healthy, weighing from 3220 to 4100 g.

CONCLUSION

Our results suggest that women who undergo arterial embolization for obstetric haemorrhage should expect to have a return of normal menses with preservation of future fertility and successful uneventful pregnancies.

[Pregnancy, tuberculosis and inappropriate antidiuretic hormone secretion]

We report a pregnant woman presenting with seizure secondary to hyponatremia by inappropriate antidiuretic hormone secretion. Aetiology was unknown urinary and lung tuberculosis. This case report presents diagnosis strategy of inappropriate antidiuretic hormone secretion and the arguments for its aetiology.

[Influence of the type of breech presentation on delivery in selected primiparous women at term]

OBJECTIVE

Study the effect of the type of breech presentation on the prognosis of delivery in selected primiparous women at term.

PATIENTS AND METHODS

We reviewed retrospectively 146 breech presentations seen between January 1, 1993 and December 12, 1999 in our unit. We limited our study to primiparous mothers at term (> or = 37 weeks gestation) who had had a normal single fetus pregnancy and who had accepted a trial of labor. We analyzed the mode of labor termination, and maternal, fetal, ovular, obstetrical and neonatal features by type of breech presentation and by type of delivery. We collected data by manual search of the patients' registered files (AUDIPOG). The chi-squared and Fisher's tests were used as appropriate for statistical analysis.

RESULTS

Spontaneous vaginal delivery was achieved in 10.3% of the cases and non-spontaneous vaginal delivery in 56.2%. Cesarean section during labor was required in 33.5%. There was no significant difference between frank breech presentation (27.4%) and incomplete breech presentation (72.6%). Maternal, fetal, ovular, obstetrical and neonatal features were not significantly different.

CONCLUSIONS

Unlike data reported by others, our series did not demonstrate any significant feature predictive of obstetrical and neonatal prognosis irrespective of the type of breech presentation in selected primiparous women at term who had had a normal pregnancy.

Abnormal placentation and selective embolization of the uterine arteries

OBJECTIVE

Abnormal placentation accounts for more than 50% of uterine artery embolization failure. The authors report their experience in this situation.

STUDY DESIGN

Seven women presented with abnormal placentation. Uterine artery embolization was carried out in emergency or prophylactic control of postpartum bleeding.

RESULTS

In five patients, control of postpartum hemorrhage was obtained without hysterectomy. In two cases with no placental removal and prophylactic procedures, hysterectomy and blood transfusion were not necessary. The manual removal of the placenta was achieved secondarily, respectively on the 25th and the 12th day.

CONCLUSIONS

The success rate of uterine artery embolization for postpartum bleeding appears to be lower with abnormal placentation. In none of the cases with the placenta present was it possible to leave the residual placenta in place. However, embolization may permit a safe waiting period and spontaneous migration of the placenta. When the diagnosis is made before delivery, prophylactic uterine artery embolization without placental removal should be considered to reduce blood transfusion and preserve fertility.

[Missed diagnosis of postpartum hemorrhage]

OBJECTIVE

The purpose of this work was to search for the reasons why the diagnosis of post-partum hemorrhage may be missed.

PATIENTS AND METHODS

We reviewed retrospectively the files 5,517 vaginal delivery patients cared for in our Gynecology and Obstetrics Unit at the Rouen University Hospital between January 1, 1997 and September 30, 1999. Among these patients, 90 (1.63%) developed anemia during the post-partum period with a 10-point fall in the hematocrit from the pre-delivery level, which corresponds to a 1 liter loss of blood, but for whom no diagnosis of hemorrhage was made. We compared this group with the population of patients who had had a diagnosis of hemorrhage. The chi-squared or Fischer's exact text were used where appropriate to compare means and calculate z.

RESULTS

Significant risk factors were: primiparity, anemia before delivery, labor induction, locorregional anesthesia, use of ocytocin, long labor with a long active phase, fever during labor, episiotomy and prolonged delay between delivery and onset of suture.

CONCLUSIONS

Missed diagnosis appeared to be related to use of visual assessment to determine the degree of bleeding, a very mediocre indicator, particularly when no means of blood collection or quantification is used. In addition, factors having an impact on the development of hemorrhage should be revisited with particular attention given to primiparous patients.

Adnexal torsion: a report on forty-five cases

OBJECTIVES

To evaluate the clinical findings, evolution of treatment and ovarian function following conservative therapy.

STUDY DESIGN

A case series of 45 patients presenting with adnexal torsion between January 1989 and June 1999. All patients were surgically treated, either conservatively or radically. Patients who had received conservative treatment, interviewed by phone and underwent ovarian sonographic examination.

RESULTS

Adnexal torsion is more frequent in young women with adnexal pathology. Conservative therapy by laparoscopy has gained increasing preference as a surgical procedure. It is safe and preserves ovarian function.

CONCLUSIONS

Conservative therapy by laparoscopy is recommended to preserve ovarian function in young women.

Plasma progesterone kinetics following surgical treatment of ectopic pregnancies

OBJECTIVES

Comparative study of plasma progesterone and betaHCG kinetics following surgical treatment of ectopic pregnancy.

STUDY DESIGN

Prospective study involving 62 patients with tubal ectopic pregnancies. Study of the kinetics of plasma progesterone and betaHCG, and the correlation coefficient between plasma progesterone and betaHCG levels during post-operative follow-up.

RESULTS

Thirty-nine patients were treated by salpingostomy and 23 by salpingectomy. Analyzing the betaHCG kinetics according to treatment revealed that both curves were convergent on day 2. Progesterone kinetics differed greatly in that they appeared "parallel and confused". Analyzing the correlation between betaHCG and progesterone levels proved the absence of a significant link.

CONCLUSIONS

Studying the kinetics of plasma progesterone after surgical treatment of ectopic pregnancies revealed a fast decrease in progesterone. Statistical analysis of the progesterone concentration showed that post-operative kinetics is fully independent from that of betaHCG. Progesterone therefore cannot be substituted to betaHCG for post-operative follow-up.

False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization

We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.

[Evaluation of clinical competence in gynecology obstetrics: an innovative approach using the Objective Structured Clinical Examination]

OBJECTIVE

The evaluation of medical student clinical competence in Obstetrics and Gynaecology using Objective Structured Clinical Examination (OSCE).

MATERIAL AND METHODS

Development of OSCE with definition of an assessment of subject, choice of clinical stations sampling, identification of components of clinical competence to be evaluated, the level of performance required, development of specification table, editing of OSCE presentation page and assessment of praticability and results exploitation.

RESULTS

Eleven station stimuli with simulated patient participation were carried out, 2 stations with a mannequin model and 1 questionnaire station.

CONCLUSION

Our experience suggests OSCE feasibility for Obstetrics and Gynaecology during the initial course of education presents adequate psychometric characteristics. This gold standard can no longer be overlooked and should be considered as a useful tool to assess medical student competence. Nevertheless, OSCE remains to be further evaluated in France.

[Which initial tests should be performed to evaluate meno-metrorrhagias? A comparison of hysterography, transvaginal sonohysterography and hysteroscopy]

OBJECTIVE

Evaluate the feasibility and the value of hysterography, sonohysterography and hysteroscopy for investigation of abnormal uterine bleeding. Method. Longitudinal blind study of thirty-eight patients consulting for abnormal uterine bleeding during pre- and post menopause. All patients underwent an hysterography and transvaginal sonohysterography, in random order, followed by an hysteroscopy with histological sample. The results were compared with the histo-pathological examination that was used for reference diagnosis. Statistical study of sensitivity, specificity and Positive and Negative Predictive Value (PPV-NPV) of each investigation; rate of agreement by the coefficient of Kappa.

RESULTS

The hysterography offers a PPV of 83% and a NPV of 100%. The interpretation errors were associated with the simple mucous hypertrophy interpreted as "hyperplasy". The limits correspond to a contrast agent allergy. The sonohysterography had a VPP of 89% and a VPN of 100%. The false positive is due to the difficulties of distinguishing the clots from the polyps. The limits correspond to the difficulties of cervix catheterization (13%). As regards the hysteroscopy, the VPP was 81.5% and the VPN of 75%. The interpretation mistakes were associated with mucous hypertrophy and the hyperplasy.

CONCLUSIONS

The most useful examination for abnormal uterine bleeding, in the first instance, is transvaginal sonography with saline instillation. A complement by Doppler study would probably make it possible to limit the false positives.

[Primary breast MALT lymphoma : apropos of one case]

A 46-year-old patient was referred for a right mammary nodule associated with a chronic mastopathy. Cytological examination suggested an inflammatory process but frozen sections concluded to carcinoma with lymphoid stroma. Histological examination found characteristic features of MALT lymphoma: reactive lymphoid follicles, lymphoplasmocytoid lymphoid proliferation and lymphoepithelial lesions. Immunohistochemistry and in situ hybridation revealed a monotypic IgGk immunoglobulin. Molecular biology techniques found a rearrangement of IgH locus. Lymphocytic perigalactophoritis was found in the remaining breast tissue. After 33 months, no tumoral recurrence occurred. Primary MALT lymphoma of the breast is exceptional and its histogenesis is unclear. The role of pre-existent inflammatory lesions in the genesis of this tumour is not established. Our observation illustrates the diagnostic difficulty and the usefulness of complementary techniques in this diagnosis. The existence of inflammation close to tumour is interesting to emphasize.

Bladder exstrophy: gynecological and obstetrical characteristics with reference to three cases

The authors report three cases of pregnancy in women treated for bladder exstrophy. Based on a review of the literature, and the follow-up of these cases, the aim of this study was to determine the prognosis of pregnancy, which is currently possible due to the progress in antibiotherapy and surgery. Nevertheless, these pregnancies need to be carefully followed-up, not only because of the complications that may occur to the mother and the infant, but also because of the type of delivery involved.

Amniotic fluid alpha-fetoprotein is not a useful biological marker of pregnancy outcome

The aim of our study was to determine if the amniotic fluid alpha-fetoprotein (AFP) level could be a useful predictive biochemical marker of pregnancy outcome. Amniotic fluid AFP measurement was prospectively carried out over a three-year period. After excluding factors susceptible to modifying AFP measurements, 587 subjects with gestational age between 14 and 20 weeks were selected to compare the amniotic fluid AFP mean levels depending on the occurrence of an adverse outcome. No significant associations between amniotic fluid AFP level and poor pregnancy outcome, i.e. pre-eclampsia, preterm delivery, premature rupture of fetal membranes, fetal growth retardation and placental abnormalities were observed. The routine measurement of amniotic fluid alpha-fetoprotein during an amniocentesis procedure was not considered useful in predicting pregnancy complications.

[Prolapse of the umbilical cord. 79 cases]

The authors are considering the prolapse of the umbilical cord, based on 79 personal observations collected in 15 years and data from the literature. They demonstrate that a simple approach (forcing back the presentation and caesarean section) decreases the perinatal mortality rate. The total rate of fetal deaths is 10 p. cent, the corrected rate of children dead on admission is 1.5 p. cent. 77 p. cent of caesarean sections were performed.

[Cervical and high vaginal aplasia with a functioning uterus. Surgical technic]

The authors describe the conservative surgical treatment of a cervical and high vaginal aplasia with functional uterus. They insist on complete resection of the aplasic area, key of the utero-vaginal continuity.

[Epidemiologic study of extra-uterine pregnancy. Apropos of 375 cases]

From a retrospective study over 11 years of 375 ectopic pregnancies, the authors have analyzed the epidemiological factors that could account for a very sensible and regular increase of the frequency of this gravidic accident. If a past history of tubal infection is usually considered as a major cause, in this series, we must mainly consider the abnormal frequency of the use of a modern contraceptive method at the time of the ectopic pregnancy, found in 32% of the cases. The place and the role of intra-uterine devices are discussed since a coil was associated with an ectopic pregnancy in 22.5% of the patients while the notion of a previous usage does not seem to be a predisposing factor: approximately only 2% of these patients had resorted to it. A hormonal contraception in progress may also lead to a late diagnosis, especially in patients using mini and micro-pills (8% of ectopic pregnancies). Finally, the advantages of conservative tubal surgery contingent on an earlier diagnosis are kept in mind by the authors because of the persistence of a high recurrence rate on the contralateral side, even after salpingectomy.

[Study of 27 endometrial samples taken with the Inocurette. Value of the method]

The authors have tested a new disposable device, the inocurette, for a histological study of the endometrium, performed on ambulatory patients without anesthesia. The indications were always the occurrence of menorrhagias or metrorrhagias and a subsequent control by curetage or hysterectomy was carried out on the first 27 cases included in this study. Sampling was done without difficulty with a preliminary dilatation of the cervix in only 4 cases and, in the whole, the procedure was not considered as painful. The reliability of the diagnosis appears satisfactory with 92% of matching results. The possibility of false negative results, even though low, urges however to pursue explorations by hysteroscopy and curetage every time there is a clinical or radiological suspicion.

[Mycoplasmas and pregnancy]

The pathogenic role of mycoplasms during pregnancy remains quite controverted, depending on the studies; for some it has an incidence on prematurity, delayed growth in utero and premature rupture of the membranes. The purpose of this study was, from a population of patients with term delivery, without any specific pathology, to verify the frequency of mothers carrying Mycoplasma Hominis or ureaplasma, and to determine the possible consequences on the newborn. A linear analysis of the evolution of the samples between D0 and D6 in the mother and the new born, shows that the presence of mycoplasms in the genital passages is as frequent in this non-risk population, and that the child may be contaminated about every other time; but this contamination appears to be very transient and without any consequences on the immediate neo-natal pathology. Systematic screening of genital mycoplasms in pregnant women does not permit, therefore, to select a group of exposed patients. In newborns who are contaminated, the risk of infection appears to be very low, but it would perhaps be desirable to study the long range future evolution of healthy carriers.

[Treatment of genital prolapse via abdominal approach and using prosthetic material. Analysis of a series of 40 cases]

From a series of 40 cases and with a 2 to 8 years follow-up, the authors have analyzed the results of the surgical treatment via abdominal approach and with the use of prosthetic material, of severe genital prolapses. A stress urinary incontinence was associated in 77.5% of the cases. Post-operative complications and recurrences are few. As far as urinary incontinence is concerned, the true corrected failure rate is close to 10% and an urodynamic exploration prior to surgery is mandatory. The main indications of this type of surgery are defined especially in case of recurring prolapse or a previous history of hysterectomy.

[Bilateral diaphragmatic hernia. Apropos of 2 cases]

Two cases of bilateral posterolateral diaphragmatic hernia are reported, due to their rarity. Both rapidly led to death. One of them was associated with severe malformations of the upper limbs. An abnormality of the cervical segment of the neural crest at the end of the first month of pregnancy may explain both types of malformations.

[Development and comparison of lecithin/sphingomyelin and palmitic acid/stearic acid ratios in amniotic fluid]

Fetal lung maturity has been studied both by silica gel chromatography of phospholipids and gas liquid chromatography of fatty acids. Lecithin/sphingomyelin (L/S) ratios and palmitic/stearic (P/S) ratios were compared. A good correlation was obtained. However, when the L/S ratio has an intermediate value (1.5 less than or equal to L/S less than 2) making it difficult to judge the fetal lung maturity, the P/S ratio expresses the lung maturity more accurately.

[Malignant cyto-trophoblastic tumors following the abortion of a mole. Their treatment with methotrexate alone or in conjunction with surgery]

We report six case histories of malignant tumours following abortion of moles. In three cases their surgical removal allowed us to control them by histology: two of these were destruens chorio-adenomata, one case only was a choriocarcinoma. In the three other cases the cure was obtained by the sole use of anti-mitotic drugs. This treatment was undertaken on bioclinical evidence of malignancy which is certainly not foolproof, but which is practical in use, when one appreciates how difficult it is to diagnose some of these post-mole tumours histologically. There is a place for the surgical treatment of these cases in spite of the usefulness of Methotrexate. This place varies according to the age of the patients and the resistance of the tumours to treatment with anti-mitotic drugs.