Late dihydroartemisinin-piperaquine treatment failure of P. falciparum malaria attack related to insufficient dosing in an obese patient

We report the case of an obese patient who experienced late failure on day28 of a well-conducted treatment with artesunate, followed by dihydroartemisinin-piperaquine (DHA-PPQ) for a severe P. falciparum malaria attack. The same P. falciparum strain was evidenced at day0 and day28. Genotypic and phenotypic resistance tests could not explain this treatment failure. The low plasma piperaquine concentration at failure may explain the poor elimination of residual parasites.

Pulmonary bacterial infections in adult patients hospitalized for COVID-19 in standard wards

OBJECTIVES

During the COVID-19 pandemic, antibiotic use was very common. However, bacterial co-/secondary infections with coronaviruses remain largely unknown in standard wards. We aimed to investigate the characteristics of pulmonary bacterial infections associated with COVID-19 in hospitalized patients.

METHODS

A retrospective monocentric observational study was conducted in Bichat hospital, France, between February 26 and April 22, 2020. All patients hospitalized in standard wards with COVID-19 (positive nasopharyngeal PCR and/or typical aspect on CT scan) and diagnosed with pulmonary bacterial infection (positive bacteriological samples) were included. Bacteriological and clinical data were collected from the microbiology laboratories and patient's medical records.

RESULTS

Twenty-three bacteriological samples from 22 patients were positive out of 2,075 screened samples (1.1%) from 784 patients (2.8%). Bacterial infection occurred within a median of 10 days after COVID-19 onset. Diagnosis of pulmonary bacterial infection was suspected on increase of oxygen requirements (20/22), productive cough or modification of sputum aspect (17/22), or fever (10/22). Positive samples included 13 sputum cultures, one FilmArray® assay on sputum samples, one bronchoalveolar lavage, six blood cultures, and two pneumococcal urinary antigen tests. The most frequent bacteria were Pseudomonas aeruginosa (6/23), Staphylococcus aureus (5/23), Streptococcus pneumoniae (4/23), Enterococcus faecalis (3/23), and Klebsiella aerogenes (3/23). No Legionella urinary antigen test was positive. Four out of 496 nasopharyngeal PCR tests (0.8%) were positive for intracellular bacteria (two Bordetella pertussis and two Mycoplasma pneumonia).

CONCLUSIONS

Pulmonary bacterial secondary infections and co-infections with SARS-CoV-2 are uncommon. Antibiotic use should remain limited in the management of COVID-19.

3 Tesla serial magnetic resonance imaging of human African trypanosomiasis (Trypanosoma brucei gambiense) and review of the literature

We report serial magnetic resonance imaging (MRI) findings and follow-up in a case of human African trypanosomiasis (HAT) presenting with limited lesions followed by early and complete resolution. We searched the literature for documented cases and reviewed MRI findings before treatment. A 30-year-old Lebanese man, who had lived in Gabon for six years, presented with a two-year history of rash, anorexia, weight loss, arthralgia, paresthesia, and hypersomnia. Previously, the patient had received corticosteroid therapy for unconfirmed ANCA-associated vasculitis. Physical examination revealed a painless chancre on the left arm located at the site of an old insect bite, enlarged cervical, axillar and inguinal lymph nodes, hepatosplenomegaly and impaired concentration. Blood analysis showed an elevated protein level (90g/L) with hypoalbuminemia (24.2g/L) and elevated IgM (26.4g/L). Bone marrow aspirate and biopsy failed to detect any parasite. Polymerase chain reaction tests on blood and cerebrospinal fluid were positive for Trypanosoma. Serology tests confirmed the diagnosis of HAT due to Trypanosoma brucei gambiense infection. 3T MRI showed lesions in the hypothalamus and basal ganglia, the internal capsule, and the mesencephalon bilaterally. Follow-up MRI showed interval progression of the abnormalities. Treatment with melarsoprol was followed by clinical improvement with regression of the lesions on the three-month MRI, then total resolution at the 10-month follow-up. This case highlights a pattern of mild MRI lesions in T. brucei gambiense HAT with a total and rapid resolution under treatment. The literature review (16 HAT cases with sufficient radiological data, included ours) revealed an MRI pattern of brain lesion distribution that could be helpful for diagnosis and orienting biological tests.

Microelimination or Not? The Changing Epidemiology of Human Immunodeficiency Virus-Hepatitis C Virus Coinfection in France 2012–2018

Background

The arrival of highly effective, well-tolerated, direct-acting antiviral agents (DAA) led to a dramatic decrease in hepatitis C virus (HCV) prevalence. Human immunodeficiency virus (HIV)-HCV–coinfected patients are deemed a priority population for HCV elimination, while a rise in recently acquired HCV infections in men who have sex with men (MSM) has been described. We describe the variations in HIV-HCV epidemiology in the French Dat’AIDS cohort.

Methods

This was a retrospective analysis of a prospective cohort of persons living with HIV (PLWH) from 2012 to 2018. We determined HCV prevalence, HCV incidence, proportion of viremic patients, treatment uptake, and mortality rate in the full cohort and by HIV risk factors.

Results

From 2012 to 2018, 50 861 PLWH with a known HCV status were followed up. During the period, HCV prevalence decreased from 15.4% to 13.5%. HCV prevalence among new HIV cases increased from 1.9% to 3.5% in MSM but remained stable in other groups. Recently acquired HCV incidence increased from 0.36/100 person-years to 1.25/100 person-years in MSM. The proportion of viremic patients decreased from 67.0% to 8.9%. MSM became the first group of viremic patients in 2018 (37.9%). Recently acquired hepatitis represented 59.2% of viremic MSM in 2018. DAA treatment uptake increased from 11.4% to 61.5%. More treatments were initiated in MSM in 2018 (41.2%) than in intravenous drug users (35.6%). In MSM, treatment at the acute phase represented 30.0% of treatments in 2018.

Conclusions

A major shift in HCV epidemiology was observed in PLWH in France from 2012 to 2018, leading to a unique situation in which the major group of HCV transmission in 2018 was MSM.

Clinical Trials Registration. NCT02898987.

Isolated right-sided Bartonella quintana endocarditis in an immunocompetent adult

Bartonella quintana is a recently recognized cause of culture-negative left-sided endocarditis. We report a case of isolated tricuspid endocarditis caused by B. quintana in a 65-year-old alcoholic man, who also had immune-complex glomerulonephritis. B. quintana was established as the cause of the endocarditis based on serological tests and on failure of extensive efforts to isolate an alternative organism. The patient improved gradually on antibiotic therapy and did not require surgery. To our knowledge, this is the first report of isolated right-sided endocarditis caused by B. quintana. Although uncommon, Bartonella should be considered in patients with isolated right-sided culture-negative endocarditis.

[Peritoneal tuberculosis]

Peritoneal tuberculosis remains a common problem in impoverished areas of the world. Immigrants and AIDS patients are two population groups at particular risk for abdominal tuberculosis in our country. The most common presenting symptoms of tuberculous peritonitis are abdominal pain, ascites and weight loss in more than 80% of cases. Results of sonographics studies are non specific and high serum CA 125 levels can be found. Pulmonary tuberculosis is concomitantly discovered in 50% of cases. Tuberculous peritonitis is of the exsudative type in 95% of cases and requires multiple studies of peritoneal fluid. Tuberculous peritonitis is suspected when exsudate and lymphocytes are present with no malignant cells, and high interferon gamma and adenosine desaminase activity. AFB is detected in the peritoneal fluid cultured conventionally in 80% of cases. Laparoscopy combined with peritoneal biopsy is effective for the diagnosis of tuberculous peritonitis in 75 to 85% of cases. Peritoneal tuberculosis is treated with antituberculous drugs for a period of nine months.

Mycobacterium tuberculosis versus nontuberculous mycobacterial infection of the lung in AIDS patients: CT and HRCT patterns

PURPOSE

The aim of this study was to determine discriminating CT and HRCT features between mycobacterial pulmonary tuberculosis and nontuberculous mycobacterial (NTMB) pulmonary infections in patients with AIDS.

METHOD

CT and HRCT scans of 52 AIDS patients with culture-proven mycobacterial infection [29 with Mycobacterium tuberculosis (MTB) and 23 with NTMB] without concomitant pulmonary infection were reviewed by two observers.

RESULTS

Nodular opacities, mainly centrilobular in distribution, were the most common finding, seen in 21 (72%) and 15 (65%) of patients with MTB and NTMB, respectively. A lower lobe predominance of centrilobular nodules was seen more commonly in NTMB (p < 0.03). Ground-glass attenuation was seen in 5 (17%) and 11 (48%) of patients with MTB and NTMB, respectively (p = 0.03). Ground-glass opacities and bronchial wall thickening affected a larger number of lobes in NTMB (p < 0.01), while centrilobular nodules involved more lobes in MTB (p < 0.01). A higher prevalence of unilateral lung involvement was seen in MTB (12 patients, 44%) than NTMB (1 patient, 5%) (p < 0.01). Enlarged lymph nodes were more frequent in patients with MTB than in those with NTMB (22, 76% vs. 10, 43%, respectively) (p < 0.02).

CONCLUSION

NTMB infection and pulmonary tuberculosis display different CT and HRCT patterns in AIDS patients, but there is considerable overlap in CT findings.

[AIDS and adolescents (epidemiology--prevention]

Adolescents aged between 15 and 19 account for 0.5% of all cases of AIDS in the western world, but this figure rises to 10% for young people aged between 20 and 25 and it is virtually certain that they were infected during adolescence. This age group is hence a preferential target for prevention. Surveys in secondary schools confirm good awareness of risks but the persistence of many sexual practices associated with the possibility of transmission.

Persistent enhancement after treatment for cerebral toxoplasmosis in patients with AIDS: predictive value for subsequent recurrence

PURPOSE

To determine the predictive imaging (CT and/or MR) features of brain toxoplasmosis recurrences in acquired immunodeficiency syndrome.

METHODS

The imaging studies of patients with brain toxoplasmosis were retrospectively reviewed. Forty-three patients with significant decrease or disappearance of brain lesions under specific treatment on follow-up imaging examinations were included. MR examinations were performed using T2- and T1-weighted sequences, before and after intravenous administration of gadolinium-DOTA.

RESULTS

A recurrence occurred in 11 (26%) of 43 cases. Ten (91%) of these 11 patients with recurrence showed focal persistent enhancement after the initial treatment of toxoplasmosis abscess. One of the 11 patients with recurrence showed no persistent enhancement; 3 patients showed persistent enhancement but had no recurrence.

CONCLUSIONS

Recurrences of brain toxoplasmosis in our series correlated with persistent contrast enhancement. We hypothesize that demonstration of persistent areas of contrast enhancement after treatment for initial toxoplasmosis may be a valuable sign for identifying patients at risk for recurrence.

Contrast-enhanced fast MRI in differentiating brain toxoplasmosis and lymphoma in AIDS patients

OBJECTIVE

Dynamic contrast-enhanced MRI was used to investigate space-occupying lesions of the brain in 22 AIDS patients without prior neurologic disease. Final diagnoses were toxoplasmosis in 13 patients (19 lesions), primary lymphoma in 7 patients (9 lesions), and both diseases in two (2 lesions, respectively).

MATERIALS AND METHODS

Dynamic contrast-enhanced MRI was done by using a heavily T1-weighted GE sequence (TR/TE 100/5, 80 degrees flip angle) performed before and repeatedly for a period of 15 min after intravenous bolus injection of Gd-DOTA (0.1 mmol/kg). Signal enhancement of the lesions and normal brain was measured as the difference of signal intensity before and after intravenous administration of contrast medium.

RESULTS

Lymphomas displayed significantly greater enhancement (mean 67%; SD 18%) than toxoplasmosis did (mean 34%; SD 16%; p < 0.001) on FLASH images. The enhancement ratios of the two lesions were significantly (p < 0.01) different between 30 and 600 s after injection. The difference between toxoplasmosis (mean 49%; SD 17%) and lymphoma (mean 69%; SD 26%) enhancement ratios on delayed SE images was less significant (p = 0.04).

CONCLUSION

Preliminary evidence suggests that dynamic sequences increase the specificity of MR in distinguishing between toxoplasmosis and lymphoma, and this has important clinical implications.

A nosocomial outbreak of multidrug-resistant Mycobacterium bovis among HIV-infected patients. A case-control study

OBJECTIVE

To identify risk factors in a nosocomial outbreak of multidrug-resistant Mycobacterium bovis (MDRMB) tuberculosis (TB) among HIV-infected patients.

DESIGN

We evaluated the study period (from the first to the last MDRMB smear-positive patients hospitalized in the unit) using a case-control study with three control groups. Since MDRMB is extremely rare, we assumed that a single strain was responsible for all six cases.

SETTING

A 19-bed infectious diseases unit in Paris, France.

PATIENTS

The index case was an AIDS patient who was hospitalized in September 1989 because of MDRMB TB. The cases were five HIV-infected patients who developed MDRMB TB between January 1990 and October 1991. Controls were randomly selected from HIV-infected patients in our unit during the study period (case-control study 1, 15 patients), during the contact period (at least one MDRMB smear-positive patient hospitalized in the unit; case-control study 2,20 patients), and patients matched according to the length of contact (case-control study 3, 24 patients).

INTERVENTIONS

After detecting the nosocomial outbreak, we took respiratory isolation precautions for all patients suspected of having active TB.

MAIN OUTCOME MEASURES

Risk factors for MDRMB nosocomial transmission, and the occurrence of new cases of MDRMB infection in HIV-infected patients and health-care workers after the introduction of isolation precautions.

RESULTS

The most important predictor of nosocomial transmission of MDRMB to HIV-infected patients was the (mean +/- s.d.) length of contact in days [cases, 22 +/- 15.8; study 1 controls, 11.2 +/- 18.9 (P = 0.07); study 2 controls, 14.6 +/- 8.5 (P = 0.043)]. Only one case of MDRMB TB resulted from exposure to MDRMB-smear-positive patient after the introduction of respiratory isolation measures. The incubation period in the single health-care worker who developed MDRMB TB was longer than in the cases.

CONCLUSION

In a nosocomial outbreak of MDRMB TB, the contact time was the main risk factor of transmission to HIV-infected patients. Respiratory isolation measures appear to be effective.