Changing Demographics and Prevalence of Body Lice among Homeless Persons, Marseille, France

The prevalence of body lice among 2,288 sheltered homeless persons in the city of Marseille during 2000–2017 was 12.2% and significantly decreased over time. We report a positive association between body lice infestations and older age, duration of stays in France for migrants, frequent consumption of alcohol, and tobacco smoking.

Epidemiology of respiratory pathogen carriage in the homeless population within two shelters in Marseille, France, 2015-2017: cross sectional 1-day surveys

Objectives

To assess risk factors for respiratory tract infection symptoms and signs in sheltered homeless people in Marseille during the winter season, including pathogen carriage.

Methods

Data on 479 male participants within two shelters who completed questionnaires and a total of 950 nasal and pharyngeal samples were collected during the winters of 2015–2017. Respiratory pathogen carriage including seven viruses and four bacteria was assessed by quantitative PCR.

Results

The homeless population was characterized by a majority of individuals of North African origin (300/479, 62.6%) with a relatively high prevalence of chronic homelessness (175/465, 37.6%). We found a high prevalence of respiratory symptoms and signs (168/476, 35.3%), a very high prevalence of bacterial carriage (313/477, 65.6%), especially Haemophilus influenzae (280/477, 58.7%), and a lower prevalence of virus carriage (51/473, 10.8%) with human rhinovirus being the most frequent (25/473, 5.3%). Differences were observed between the microbial communities of the nose and throat. Duration of homelessness (odds ratio (OR) 1.77, p 0.017), chronic respiratory diseases (OR 5.27, p <0.0001) and visiting countries of origin for migrants (OR 1.68, p 0.035) were identified as independent risk factors for respiratory symptoms and signs. A strong association between virus (OR 2.40, p 0.012) or Streptococcus pneumoniae (OR 2.32, p 0.014) carriage and respiratory symptoms and signs was also found.

Conclusions

These findings allowed identification of the individuals at higher risk for contracting respiratory tract infections to better target preventive measures aimed at limiting the transmission of these diseases in this setting.

Prospective comparative study of characteristics associated with influenza A and B in adults

OBJECTIVES

To describe and compare the epidemiological characteristics associated with influenza type A and B as well as the characteristics associated with influenza pneumonia. The secondary objective was to evaluate the performance of influenza rapid diagnostic tests (RDT) in the emergency department.

PATIENTS AND METHODS

Prospective study, including 251 adult patients admitted to the emergency department during the 2013-2014 influenza outbreaks for flu-like illness confirmed by RT-PCR.

RESULTS

A total of 106 patients were infected with influenza type B (42%) and 145 with influenza type A (58%). Mean age was 56 and the sex-ratio was 0.9. In a multivariate analysis, the only factor independently related with the type of influenza strain was the patient's age. Overall, 17% of influenza-infected patients were vaccinated and 38% presented with pneumonia, with no significant difference between strains. In a univariate analysis, the risk factors associated with the occurrence of pneumonia were age, vaccination, and chronic obstructive pulmonary disease. Only 22% of samples positive by RT-PCR for influenza B and 40% for influenza A were positive by RDT.

CONCLUSION

Influenza type A and type B had similar clinical and biological signs, including severity. Influenza type B should not be neglected. Any emergency department may use the RDT for its ease-of-use and rapidity. However, its low sensitivity should be taken into consideration when interpreting results.

Real-time laboratory surveillance of sexually-transmissible infections in Marseille University hospitals reveals rise of gonorrhoea, syphilis and human immunodeficiency virus seroconversions in 2012

Real-time systematic monitoring of the number of infections diagnosed in our clinical microbiology laboratory in Marseille recently drew attention to the fact that the incidence of gonorrhoea was 10-fold greater from September through December 2012 than during same months of previous years. We also found an increase in the annual incidence of syphilis and human immunodeficiency virus seroconversion. Our system allowed timely identification of an increase in sexually-transmitted infections in Marseille for the whole year of 2012.

Real-time laboratory surveillance of sexually-transmissible infections in Marseille University hospitals reveals rise of gonorrhoea, syphilis and human immunodeficiency virus seroconversions in 2012

Real-time systematic monitoring of the number of infections diagnosed in our clinical microbiology laboratory in Marseille recently drew attention to the fact that the incidence of gonorrhoea was 10-fold greater from September through December 2012 than during same months of previous years. We also found an increase in the annual incidence of syphilis and human immunodeficiency virus seroconversion. Our system allowed timely identification of an increase in sexually-transmitted infections in Marseille for the whole year of 2012.

Detection of a knockdown resistance mutation associated with permethrin resistance in the body louse Pediculus humanus corporis by use of melting curve analysis genotyping

Louse-borne diseases are prevalent in the homeless, and body louse eradication has thus far been unsuccessful in this population. We aim to develop a rapid and robust genotyping method usable in large field-based clinical studies to monitor permethrin resistance in the human body louse Pediculus humanus corporis. We assessed a melting curve analysis genotyping method based on real-time PCR using hybridization probes to detect the M815I-T917I-L920F knockdown resistance (kdr) mutation in the paraorthologous voltage-sensitive sodium channel (VSSC) α subunit gene, which is associated with permethrin resistance. The 908-bp DNA fragment of the VSSC gene, encoding the α subunit of the sodium channel and encompassing the three mutation sites, was PCR sequenced from 65 lice collected from a homeless population. We noted a high prevalence of the 3 indicated mutations in the body lice collected from homeless people (100% for the M815I and L920F mutations and 56.73% for the T917I mutation). These results were confirmed by melting curve analysis genotyping, which had a calculated sensitivity of 100% for the M815I and T917I mutations and of 98% for the L920F mutation. The specificity was 100% for M815I and L920F and 96% for T917I. Melting curve analysis genotyping is a fast, sensitive, and specific tool that is fully compatible with the analysis of a large number of samples in epidemiological surveys, allowing the simultaneous genotyping of 96 samples in just over an hour (75 min). Thus, it is perfectly suited for the epidemiological monitoring of permethrin resistance in human body lice in large-scale clinical studies.

Human louse-transmitted infectious diseases

Several of the infectious diseases associated with human lice are life-threatening, including epidemic typhus, relapsing fever, and trench fever, which are caused by Rickettsia prowazekii, Borrelia recurrentis, and Bartonella quintana, respectively. Although these diseases have been known for several centuries, they remain a major public health concern in populations living in poor-hygiene conditions because of war, social disruption, severe poverty, or gaps in public health management. Poor-hygiene conditions favour a higher prevalence of body lice, which are the main vectors for these diseases. Trench fever has been reported in both developing and developed countries in populations living in poor conditions, such as homeless individuals. In contrast, outbreaks of epidemic typhus and epidemic relapsing fever have occurred in jails and refugee camps in developing countries. However, reports of a significantly high seroprevalence for epidemic typhus and epidemic relapsing fever in the homeless populations of developed countries suggest that these populations remain at high risk for outbreaks of these diseases. Additionally, experimental laboratory studies have demonstrated that the body louse can transmit other emerging or re-emerging pathogens, such as Acinetobacter baumannii and Yersinia pestis. Therefore, a strict survey of louse-borne diseases and the implementation of efficient delousing strategies in these populations should be public health priorities.

Murine typhus in the homeless

Homeless populations are particularly exposed to many vector-borne diseases because of their poor living conditions. We tested sera from 299 homeless people recruited in 2010 and 2011 in Marseilles, France for antibodies to Rickettsia typhi by microimmunofluorescence using a titer of 1:25 as a cut-off titer, and we confirmed the results by Western blot and cross-adsorption studies. Sixty-three persons (22%) had antibodies against R. typhi. The murine typhus seroprevalence rates have significantly increased in homeless populations between the 2000-2003 and 2010-2011 periods. These findings indicate that the homeless are increasingly exposed to flea-borne murine typhus in Marseilles. One might suggest that multiple strikes of sanitation workers resulting in the increase of waste and construction sites combined with the poor living conditions of the homeless expose this population to rodents and their fleas. Further annual studies are necessary to follow rodent-associated diseases among homeless people in Marseille.

Revolutionizing clinical microbiology laboratory organization in hospitals with in situ point-of-care

BACKGROUND

Clinical microbiology may direct decisions regarding hospitalization, isolation and anti-infective therapy, but it is not effective at the time of early care. Point-of-care (POC) tests have been developed for this purpose.

METHODS AND FINDINGS

One pilot POC-lab was located close to the core laboratory and emergency ward to test the proof of concept. A second POC-lab was located inside the emergency ward of a distant hospital without a microbiology laboratory. Twenty-three molecular and immuno-detection tests, which were technically undemanding, were progressively implemented, with results obtained in less than four hours. From 2008 to 2010, 51,179 tests yielded 6,244 diagnoses. The second POC-lab detected contagious pathogens in 982 patients who benefited from targeted isolation measures, including those undertaken during the influenza outbreak. POC tests prevented unnecessary treatment of patients with non-streptococcal tonsillitis (n = 1,844) and pregnant women negative for Streptococcus agalactiae carriage (n = 763). The cerebrospinal fluid culture remained sterile in 50% of the 49 patients with bacterial meningitis, therefore antibiotic treatment was guided by the molecular tests performed in the POC-labs. With regard to enterovirus meningitis, the mean length-of-stay of infected patients over 15 years old significantly decreased from 2008 to 2010 compared with 2005 when the POC was not in place (1.43±1.09 versus 2.91±2.31 days; p = 0.0009). Altogether, patients who received POC tests were immediately discharged nearly thrice as often as patients who underwent a conventional diagnostic procedure.

CONCLUSIONS

The on-site POC-lab met physicians' needs and influenced the management of 8% of the patients that presented to emergency wards. This strategy might represent a major evolution of decision-making regarding the management of infectious diseases and patient care.

Measles among healthcare workers: a potential for nosocomial outbreaks

We report here 14 cases of measles among healthcare workers (HCWs) in Public Hospitals of Marseilles, France that occurred between April and November 2010. All cases but one were under 30 years of age. Following the identification of these cases, we checked the immune status among 154 HCWs who volunteered to take part in the study and showed that 93% and 88% were immune against measles and mumps respectively. HCWs non-immunised against measles were all under 30 years of age.

Measles among healthcare workers: a potential for nosocomial outbreaks

We report here 14 cases of measles among healthcare workers (HCWs) in Public Hospitals of Marseilles, France that occurred between April and November 2010. All cases but one were under 30 years of age. Following the identification of these cases, we checked the immune status among 154 HCWs who volunteered to take part in the study and showed that 93% and 88% were immune against measles and mumps respectively. HCWs non-immunised against measles were all under 30 years of age.

Likely correlation between sources of information and acceptability of A/H1N1 swine-origin influenza virus vaccine in Marseille, France

BACKGROUND

In France, there was a reluctance to accept vaccination against the A/H1N1 pandemic influenza virus despite government recommendation and investment in the vaccine programme.

METHODS AND FINDINGS

We examined the willingness of different populations to accept A/H1N1 vaccination (i) in a French hospital among 3315 employees immunized either by in-house medical personnel or mobile teams of MDs and (ii) in a shelter housing 250 homeless persons. Google was used to assess the volume of enquiries concerning incidence of influenza. We analyzed the information on vaccination provided by Google, the website of the major French newspapers, and PubMed. Two trust Surveys were used to assess public opinion on the trustworthiness of people in different professions. Paramedics were significantly more reluctant to accept immunisation than qualified medical staff. Acceptance was significantly increased when recommended directly by MDs. Anecdotal cases of directly observed severe infections were followed by enhanced acceptance of paramedical staff. Scientific literature was significantly more in favour of vaccination than Google and French newspaper websites. In the case of the newspaper websites, information correlated with their recognised political reputations, although they would presumably claim independence from political bias. The Trust Surveys showed that politicians were highly dis-trusted in contrast with doctors and pharmacists who were considered much more trustworthy.

CONCLUSIONS

The low uptake of the vaccine could reflect failure to convey high quality medical information and advice relating to the benefits of being vaccinated. We believe that the media and internet contributed to this problem by raising concerns within the general population and that failure to involve GPs in the control programme may have been a mistake. GPs are highly regarded by the public and can provide face-to-face professional advice and information. The top-down strategy of vaccine programme management and information delivered by the Ministry of Health could have aggravated the problem, because the general population does not always trust politicians.

H1N1 2009 pandemic flu vaccination campaign: The Homeless lesson

Homeless are deprived people of developed countries that have a particularly low vaccine coverage and are exposed to vaccine preventable infectious diseases. We report here the efficiency of a voluntary based one-day snapshot influenza vaccination in homeless shelter of Marseille, France, which allowed to obtain a 46.9% H1N1 pandemic vaccine coverage while at the same time only 6% of the French population has been vaccinated.

Contribution of a shelter-based survey for screening respiratory diseases in the homeless

BACKGROUND

The homeless are at very high risk for both respiratory diseases and poor access to health care delivery systems. The aim of this study was to assess the contribution of a shelter-based survey to identify respiratory diseases in the homeless population in Marseilles, in order to further develop preventive interventions.

METHODS

A prevalence survey of respiratory diseases was conducted in two homeless shelters in Marseilles, in February 2005. A multidisciplinary team including infectious diseases specialists, lung specialists, residents, nurses, physiotherapists and X-ray technicians visited the two shelters. Interview, physical examination, sputum sampling for Mycobacterium tuberculosis detection, nasal swabs for virus detection and chest X-rays were performed in shelters. Chest X-rays were subsequently analysed by a pneumonologist and subjects found to have radiological abnormalities were hospitalized for further investigations.

RESULTS

Of the 221 homeless persons enrolled, 110/221 (50%) had at least one respiratory manifestations. Chest X-rays were abnormal in 14 persons. Active tuberculosis was diagnosed in two, influenza in two, respiratory syncytial virus infection in two, acute pneumonia in one, asthma in two, lung cancer in one, acute bronchitis in 23, chronic bronchitis in 42, and exacerbation of chronic obstructive pulmonary disease in 22 persons, respectively.

CONCLUSION

Our shelter-based survey, including clinical evaluation and chest radiographic screening, shows that this approach can be useful to control and prevent respiratory diseases among the homeless. However, further studies are necessary to determine the magnitude of influenza in the homeless, the impact of influenza immunization and optimal frequency of interventions in shelters.

Preventing and controlling emerging and reemerging transmissible diseases in the homeless

Homelessness is an increasing public health problem. Because of poor living conditions and limited access to healthcare systems, homeless persons are exposed to many communicable infections. We summarize the intervention measures reported to be efficient for the control and the prevention of common transmissible infections among homeless populations. Evidence suggests that appropriate street- or shelter-based interventions for targeted populations are the most efficient methods. Depending on the populations targeted, these interventions may include education, free condom distribution, syringe and needle prescription programs, chest radiography screening for tuberculosis, directly observed therapy for tuberculosis treatment, improvement of personal clothing and bedding hygiene, and widespread use of ivermectin for scabies and body louse infestation. Systematic vaccination against hepatitis B virus, hepatitis A virus, influenza, Streptococcus pneumoniae, and diphtheria is strongly recommended. National public health programs specific to homeless populations are required.

Preventing and controlling emerging and reemerging transmissible diseases in the homeless

Appropriate street- or shelter-based interventions for targeted populations are most effective.

Homelessness is an increasing public health problem. Because of poor living conditions and limited access to healthcare systems, homeless persons are exposed to many communicable infections. We summarize the intervention measures reported to be efficient for the control and the prevention of common transmissible infections among homeless populations. Evidence suggests that appropriate street- or shelter-based interventions for targeted populations are the most efficient methods. Depending on the populations targeted, these interventions may include education, free condom distribution, syringe and needle prescription programs, chest radiography screening for tuberculosis, directly observed therapy for tuberculosis treatment, improvement of personal clothing and bedding hygiene, and widespread use of ivermectin for scabies and body louse infestation. Systematic vaccination against hepatitis B virus, hepatitis A virus, influenza, Streptococcus pneumoniae, and diphtheria is strongly recommended. National public health programs specific to homeless populations are required.

The effect of a single dose of oral ivermectin on pruritus in the homeless

BACKGROUND

Homeless people commonly present with ectoparasite-based pruritus. We evaluated the efficacy of a single dose of ivermectin to reduce the pruritus prevalence in a homeless population.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial from January 2006 to April 2006 in two homeless shelters in the city of Marseille, France. Homeless people complaining of pruritus were randomized to receive either ivermectin (24 mg) or placebo. Follow-up visits were planned at day 14 and day 28 after the inclusion to assess the outcome of pruritus.

RESULTS

Forty-two subjects with pruritus were randomized to the ivermectin group and 40 to the placebo group. On day 14, pruritus was reported by significantly more subjects in the placebo group than those in the ivermectin group for both the per-protocol (PP) population (91.42% versus 68.57%, P = 0.014) and the intention-to-treat (ITT) population (92.5% versus 73.80%, P = 0.038). No significant effect was observed at day 28. Ivermectin was the only independent factor associated with the absence of pruritus at day 14 in both PP population [OR: 4.60 (95% CI:1.13; 18.73), P = 0.033] and ITT population [OR: 4.38 (95% CI: 1.07; 17.77), P = 0.039].

CONCLUSIONS

A single dose of oral ivermectin has a transient beneficial effect on the reduction of the prevalence of pruritus in the homeless population. More studies are required to assess the efficacy of multiple repeated treatments with ivermectin to reduce scabies and body lice endemic among homeless people with pruritus and the impact of such treatment on this population.

Antimalarial drug susceptibility and point mutations associated with drug resistance in 248 Plasmodium falciparum isolates imported from Comoros to Marseille, France in 2004 2006

A total of 248 Plasmodium falciparum isolates were sampled in travelers with malaria who came to Marseille, France from Comoros to investigate in vitro activities of antimalarial drugs and molecular markers of drug resistance. Of the 248 isolates, 126 were maintained in culture. Of these, 53% were resistant to chloroquine, and 3% had reduced susceptibility to quinine, mefloquine, and atovaquone; 1% had reduced susceptibility to halofantrine and dihydroartemisinin; 7% had reduced susceptibility to monodesethylamodiaquine; 37% had reduced susceptibility to cycloguanil; and none had reduced susceptibility to lumefantrine. Resistance-associated point mutations were screened in 207 isolates. No mutations in the cytochrome b gene were found. Of the 207 isolates, 119 (58%) had a mutation in the P. falciparum dihydrofolate reductase (Pfdhfr) gene at codon 108, 6 (5%) had mutations in both Pfdhfr codon 108 and the P. falciparum dihydropteroate synthase codon 437, and 115 (56%) had the chloroquine resistance-associated K76T mutation in the P. falciparum chloroquine resistance transporter gene. This study represents a unique opportunity to improve surveillance of P. falciparum drug resistance in Comoros with consequences for treatment and chemoprophylaxis guidelines.

[Imported malaria at the Marseilles Hôpital-Nord, France: a prospective study on 352 cases between 2001 and 2003]

OBJECTIVE

The authors had for aim to study epidemiological, clinical, and parasitological characteristics, as well as regimen received, of imported malaria cases hospitalised at the North University Hospital, in Marseilles, France.

DESIGN

The patients presenting with imported malaria included in this study were hospitalised in the infectious and tropical diseases unit and in the pediatrics unit at the North University Hospital, from January 1, 2001 to December 31, 2003. Variables were prospectively collected and recorded.

RESULTS

352 patients including 240 adults and 112 children were included. Most of them (67% of the adults and 92% of the children) were contaminated during a trip to the Comoros Islands. Plasmodium falciparum was the most common species identified. 97.5% of adult and 98% of child patients back from Comoros did not take any chemoprophylaxis against malaria or took inadequate regimens. Halofantrin was the most commonly used drug for children to treat uncomplicated P. falciparum malaria. In adults, atovaquone-proguanil was used as a first line drug in the absence of vomiting, and a 3-day intravenous regimen of quinine-clindamycin in case of vomiting.

CONCLUSION

The specificity of imported malaria in Marseilles is the high proportion of Comorian patients who go back home periodically to visit friends and relatives. A better education of the Comorian population in Marseilles, regarding malaria risks and prophylaxis, needs to be implemented.

Severe imported malaria: Clinical presentation at the time of hospital admission and outcome in 42 cases diagnosed from 1996 to 2002

The objectives of this retrospective study were to describe initial clinical profiles and subsequent outcome of adult patients in France who were diagnosed with severe imported malaria, as defined by the World Health Organization (WHO). Forty-two patients diagnosed from 1996 to 2002 were included (median age: 30 years, men: 78%, non-immune persons: 74%, return from Africa: 100%, inappropriate antimalarial chemoprophylaxis: 95%). At the time of hospital admission, jaundice (62%), hyperparasitemia (56%), and prostration (52%) were the most frequent findings, followed by acute renal failure (31%). Other findings, as described by the WHO criteria, were less common. Twenty-three patients presented only with jaundice, hyperparasitemia, or prostration in isolation, or in combination. Of these 23, five non-immune persons subsequently developed coma, shock, acute respiratory distress syndrome or acute renal failure; this led to death in 2 of these cases. This suggests that non-immune persons with imported malaria who present with jaundice, hyperparasitemia, or prostration should be admitted to the intensive care unit for close monitoring.

Imported Brucellosis associated with Plasmodium falciparum malaria in a traveler returning from the tropics

We report a microbiologically confirmed case of Brucella melitensis and Plasmodium falciparum malaria coinfection in a febrile traveler returning from Chad, Africa. The patient had been doing veterinary research in rural Chad; during that time she took no antimalarial chemoprophylaxis. Our report highlights the importance of blood cultures as well as malaria smears in febrile travelers returning from the tropics.

Prevalence of skin infections in sheltered homeless

In an attempt to determine the prevalence of various skin infections in the homeless population in Marseilles, France, we undertook a case control study. Cases were recruited among institutionalized homeless subjects during two snapshot investigations conducted in January 2002 and 2003 respectively. The control subjects were recruited from among those who presented at a clinic for pre-travel advice. We recruited 498 cases and 200 control subjects. Compared to control subjects, a significantly higher proportion of cases had skin diseases (38% versus 0.5%; p < 0.0001). Pruritus, body-lice infestation, scratching lesions, folliculitis, tinea pedis, scabies and impetigo (ecthyma) were strongly significantly associated with homelessness. The higher prevalence of skin infections in the homeless people mainly results from the body-louse infestation, scabies, bacterial super-infection of skin surfaces that have been breached by frequent scratching and tinea pedis due to poor foot hygiene.

Autochthonous epidemic typhus associated with Bartonella quintana bacteremia in a homeless person

Trench fever, a louse-borne disease caused by Bartonella quintana, is reemerging in homeless persons. Epidemic typhus is another life-threatening louse-borne disease caused by Rickettsia prowazekii and known to occur in conditions of war, famine, refugee camps, cold weather, poverty, or lapses in public health. We report the first case of seroconversion to R. prowazekii in a homeless person of Marseilles, France. This was associated with B. quintana bacteremia. Although no outbreaks of typhus have been notified yet in the homeless population, this disease is likely to reemerge in such situation.

Q fever outbreak in homeless shelter

Urban outbreaks of Q fever have occurred after exposure to slaughterhouses or parturient cats. We detected an outbreak of Q fever in a homeless shelter in Marseilles. Investigations showed that the main factors exposing persons to Coxiella burnetii were an abandoned slaughterhouse, used for an annual Muslim sheep feast, and wind.

Hypertriglyceridemia as an indicator of the severity of falciparum malaria in returned travelers: a clinical retrospective study

To test the hypothesis that the magnitude of plasma triglyceride changes could be related to the severity of falciparum malaria, we performed a retrospective case-control study from January 1999 to December 2000 among hospitalized patients with fever who were returning to France from the tropics. Plasma triglycerides were measured in patients with severe falciparum malaria ( n=13), mild falciparum malaria ( n=169), non- falciparum malaria ( n=20) and controls ( n=55). Triglyceride level was significantly higher in the malaria group than in controls [mean values were 2.17+/-1.43 mmol/l versus 1.30+/-0.70 mmol/l, respectively ( P<0.0001)]. Triglyceride level was also significantly higher in severe than in mild malaria [4.78+/-1.93 mmol/l versus 1.94+/-1.11, respectively ( P<0.00001)]. Hypertriglyceridemia (>1.80 mmol/l) was noted in all the patients with severe malaria, compared to 37% of patients with mild disease ( P<0.001). Although further studies are needed, these results define the relevance of hypertriglyceridemia as an indicator of the severity of falciparum malaria.

Imported Dengue in French University Hospitals: a 6-year survey

Dengue fever (DF) is a mosquito-transmitted acute disease caused by any of four dengue flavivirus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4) which is becoming a major public health problem in intertropical areas.1 DF is increasingly observed in febrile travelers returning from tropical areas,2 especially those returning from the Caribbean islands and Southeast Asia, but it is rarely diagnosed in travelers returning from Africa.3-8 Diagnosis is often serologic, and in most cases is not confirmed; virus isolation remains exceptional. In a retrospective study of 44 cases of imported DF diagnosed in France, we found that the epidemiologic, clinical and diagnostic characteristics of these cases were similar to those reported in other previous published studies; diagnosis was carried out with serology, and no virus isolation was reported. To draw the attention of physicians from nonendemic areas to the possible occurrence of dengue infection in febrile travelers from all tropical countries, including those in Africa, and to reinforce recommendations required to establish diagnosis with certainty, we report herein a prospective study from 1998-1999 which we compiled with our previously published data.

Chlamydia pneumoniae, but not Bartonella quintana, is associated with coronary heart disease: results of a French case-control study

Serologic cross-reactivity has been demonstrated between Bartonella quintana and Chlamydia pneumoniae. Therefore, the association between antibodies to C. pneumoniae and coronary heart disease (CHD) as described in the literature may be due to antibodies cross-reacting with B. quintana. To investigate this hypothesis, we evaluated, in a case-control study, the prevalence of C. pneumoniae and B. quintana antibodies among 296 cases with angiographically significant artery lesions and 170 controls without angiographically demonstrable coronary artery disease. The prevalence of C. pneumoniae antibodies was higher among cases than among controls: 69% versus 49% (P < 0.001; OR 1.39; 95% CI (1.55; 3.52)). Multiple logistic regression demonstrated that C. pneumoniae seropositivity is an independent risk factor for CHD (adjusted OR 2.31; 95% CI (1.49; 3.60)). No statistically significant association was demonstrated between B. quintana seropositivity and CHD. Antibodies to both C. pneumoniae and B. quintana were found in nine subjects (seven cases and two controls), suggesting co-infection rather than cross-reactivity.

Triangular test applied to the clinical trial of azithromycin against relapses in Plasmodium vivax infections

BACKGROUND

Sequential analysis enables repeated statistical analyses to be performed throughout a trial recruitment period, while maintaining a pre-specified power and type I error. Thus the trial can be stopped as soon as the information accumulated is considered sufficient to reach a conclusion. Sequential tests are easy to use and their statistical properties are especially suitable to trials with very straightforward objectives such as non-comparative phase II trials. We report on a phase II study based on the triangular test (TT) aiming at assessing the effectiveness of azithromycin in preventing Plasmodium vivax relapses.

METHODS

To test whether the P. vivax relapse rate was either <12% or >or= 45% in patients treated with azithromycin, a sequential analysis based on the TT was as used. Patients infected with P. vivax were treated with azithromycin, 1.2 g daily, for 7 days. The onset of a relapse infection was monitored.

RESULTS

Five patients presenting with an acute P. vivax infection were included in the study. All the patients were initially cured. Three patients reported mild gastrointestinal adverse effects. When the third patient relapsed, the sample path crossed the upper boundary of the TT, and the trial was stopped.

CONCLUSIONS

Using the triangular test, with only a small number of patients, we concluded that azithromycin was not effective enough in preventing P. vivax relapses to warrant further evaluation in phase III. It is suggested that a wider use of sequential analysis in phase II anti-infective drugs trials may have financial and ethical benefits.

Contribution of nonspecific laboratory test to the diagnosis of malaria in febrile travelers returning from endemic areas: value of hypocholesterolemia

BACKGROUND

The gold standard in diagnosis of malaria is microscopic detection of malaria parasites in thin blood smears. However, the sensitivity and specificity of blood smears depend mostly on the experience of the examiner. In the traveler returning from the tropics, diagnosis of malaria may be difficult when the parasitemia is low. In this circumstance any indicator that suggests the diagnosis of malaria is of great interest. The aim of this study is to determine the value of hypocholesterolemia to the diagnosis of imported malaria.

METHOD

A retrospective case-control study was performed among hospitalized patients with fever returning from a malaria-endemic area, to compare the results of routine biological parameters of 129 malaria cases with those of 92 control patients.

RESULTS

Multivariate analysis, using a logistic regression model demonstrates that hypocholesterolemia was the strongest parameter associated with malaria (adjusted odds ratio [OR]: 75.22, 95% confidence interval [CI] 4.60-1227.78) and the most specific (98%, 95% CI 0.95-1.0). The most sensitive abnormality was thrombocytopenia (82%, 95% CI-0.77 0.87). With a malaria prevalence of 52% in our population study, hypocholesterolemia has the strongest positive predictive value among routine biological parameters for malaria diagnosis (96%). The combination of hypocholesterolemia and thrombocytopenia was always associated with diagnosis of malaria in this study.

CONCLUSION

These results show that hypocholesterolemia is significantly associated with malaria. Therefore, in the setting of negative thin and thick blood smears, the presence of hypocholesterolemia, particularly when it is combined with thrombocytopenia, in a febrile traveler returning from a malaria-endemic area, should prompt repetition and careful analysis of blood smears to avoid misdiagnosis.

Pre- and in-hospital management of community-acquired pneumonia in southern France, 1998-99

A prospective, hospital-based, multicenter study was undertaken to identify the reasons for hospital admission, to describe antibiotic treatment before and during hospitalization, and to determine the outcome of community-acquired pneumonia (CAP). Data collected included prehospital management of CAP, Pneumonia Outcome Research Team (PORT) classification on admission, in-hospital antibiotic treatment, and predictors of death within 30 days. Among the 215 patients (mean age, 66.7 years; M:F ratio, 1.1) recruited, 24 (11.2%) were living in nursing homes. CAP had been diagnosed prior to admission in 55 (25.6%) patients. At admission, 75 (34.9%) patients had a low risk of death (PORT classification I-II). A pathogen was isolated for 55 (25.6%) patients, primarily Streptococcus pneumoniae (n=18), atypical agents (n=16), influenza virus (n=10), and respiratory syncytial virus (n=4). Amoxicillin (with or without clavulanate), cefotaxime, or ceftriaxone monotherapy was prescribed to 121 (56.3%) patients. Dual combination therapy was prescribed to patients at higher risk of death (PORT classification III-V; OR, 3.09). Mortality was 7%. Logistic-regression analysis identified nursing-home residency (OR, 8.36), serum creatinine > or =88 micromol/l (OR, 7.88), and Pneumonia Outcome Research Team classification (OR, 1.02) as independent predictors of death. CAP remains a serious disease for elderly persons living in nursing homes. This population should benefit from immunization with pneumococcal and influenza vaccines.

[A classical form of actinomycoses involving the mouth, face bones, orbit and base of the cranium in an African patient]

Osteitis due to actinomycosis is now an uncommon clinical entity in industrialized countries. This report describes a classic case of imported actinomycosis involving the buccal cavity, facial bones, orbit and skull base. For two years after the onset, various diagnoses followed by different medical as well as surgical treatments were unsuccessfully attempted first in Senegal then in Italy. Proper diagnosis was finally established in Marseille, France, on the basis of histological findings after extensive surgical biopsy. The patient was treated with high-dose intravenous penicillin G for four weeks followed by daily oral administration of amoxicillin for one year. Surgical reconstruction could not be carried out before the patient's return to Senegal. The pitfalls of diagnosis and treatment of actinomycosis are discussed.

Controlled trial of 3-day quinine-clindamycin treatment versus 7-day quinine treatment for adult travelers with uncomplicated falciparum malaria imported from the tropics

We conducted a randomized, double-blind, placebo-controlled trial to compare a 3-day quinine-clindamycin regimen (group QC) with a 7-day quinine regimen (group Q) for the treatment of uncomplicated Plasmodium falciparum malaria in travelers returning from the tropics. A total of 55 and 53 patients in groups Q and QC were analyzed, respectively. Adverse effects were similar in both groups, although two patients in group Q had severe adverse reactions, leading to the cessation of treatment. The 28-day cure rate for the evaluated patients (per-protocol analysis) was 100% for group QC, whereas it was 96.3% for group Q (P = 0.5). The 28-day cure rate in the intention-to-treat analysis was 96.2% for group QC, whereas it was 94.6% for group Q (P = 1). There were no significant differences between the two regimens with regard to parasite and fever clearance times. Our study shows that the 3-day quinine-clindamycin regimen is well tolerated and compares favorably with a 7-day quinine treatment. This short-term regimen had previously been evaluated only in areas of endemicity. According to our results, the 3-day quinine-clindamycin regimen may be an alternative for the treatment of imported uncomplicated P. falciparum malaria in travelers returning from the tropics.

[Imported dengue: study of 44 cases observed from 1994 to 1997 in 9 university hospital centers. Infectio-Sud-France group]

Imported dengue is increasingly observed in non endemic countries. We report a retrospective study of 44 cases of dengue fever diagnosed in nine french university hospitals between 1994 and 1997. The patients were aged between 13 and 67 years. Most of them were tourists and had been traveling for a few weeks, in French West Indies and French Guyana (18), South-East Asia (10), India (7) or Polynesia (4). Only, two contracted the disease in Africa. The onset of symptoms preceded the return or followed it within 7 days. The most frequent clinical presentation was a febrile and painful syndrome. Cutaneous manifestations (rash or macular exanthem) were observed in 59% of cases, digestive symptoms in 50%, pharyngitis and/or cough in 25%, microadenopathy in 20%, moderate mucous haemorrhagic manifestations in 16% and neuropsychiatric manifestations in 14%. The common biological abnormalities were thrombocytopenia (84%), leukopenia (59%), and elevated transminases (57%). The diagnosis, orientated by negativity of malaria smears, the knowledge of an epidemic in the visited country, or occurrence of similar cases in the entourage, were argued by serological results: presence of anti-DEN IgM in 25 cases, serological conversion (anti- DEN IgG) in 7 cases or very high seropositivity (anti-DEN IgG > 1/1280) in 12 cases. No virus isolation was obtained.

[Calcified splenic abscess, colonic fistula and ascites in a chronic carrier of Salmonella typhi]

We report the unusual case of a patient with chronic carriage of Salmonella typhi who presented with partially calcified splenic abscess linked to colic fistula and ascitis. The colic fistula could be secondary to ischemic necrosis by left colon compression due to spleen large abscess. Fistula was evidenced by abdominal computed tomography scan and confirmed by barium enema. The possible etiologies of ascitis are either tuberculosis or ascitic peritonitis secondary to the fistulisation; nevertheless, the role of segmentary portal located hypertension cannot be completely excluded. The splenic abscess was probably due to Salmonella typhi which was only isolated from stool specimens. The calcified splenic abscess was the evidence that the infection had occurred first. In addition, the isolation of Salmonella typhi in stool cultures six months after the subject had returned from the Comores proved the chronic carriage. Treatment by splenectomy and left colectomy was successful in this patient.

[Periarteritis nodosa disclosed by epilepsy in a drug addict with hepatitis B and C virus carrier state]

The authors report a case of periarteritis nodosa (PAN) with an inaugural symptom of febril epilepsy. The patient was drug addict with hepatitis B and C virus. A toxoplasmic lesion originally noted on the cranial computed tomography scan was confirmed by cerebral magnetic resonance imaging showing encephalitis, and a diagnosis of periarteritis nodosa was suggested by clinical signs and laboratory data. The responsibility of hepatitis B virus in the genesis of this PAN seems quite certain whereas possible others factors such as hepatitis C virus or cocaine are discussed.

Eucaryotic cells protect Borrelia burgdorferi from the action of penicillin and ceftriaxone but not from the action of doxycycline and erythromycin

Despite appropriate antibiotic treatment, Lyme disease patients may have relapses or may develop chronic manifestations. The intracellular location of Borrelia burgdorferi suggests that antibiotics that penetrate cells will have greater efficiency. Doxycycline or erythromycin was more effective than penicillin or ceftriaxone in killing B. burgdorferi when the organism was grown in the presence of eucaryotic cells.

[Necrotizing hepatic granuloma of brucellosis origin. Apropos of a case]

The authors report on a case of febrile necrotizing brucellosis hepatic granulomatosis in a patient living in brucellosis endemia areas. This hepatic localization of brucellosis is rare: to our knowledge only 28 cases have been described in the literature. The bacteriological diagnosis was not established by blood or abscess pus cultures, but by Brucella serology only. Surgery completed by biantibiotherapy have permitted a complete recovery.