[Syphilis outbreak in southeast France]. / Epidémie de syphilis dans le sud-est de la France.

BACKGROUND: Since 2000, syphilis has reappeared in the form of an epidemic in France and more particularly, in the Paris region. However, there is little available data concerning other regions of France. The purpose of this study was to identify the chief characteristics of this epidemic in the Côte d'Azur region. PATIENTS AND METHODS: Between January 2001 and July 2003, cases of syphilis were collated by the Department of Dermatology and Infectious Diseases of Nice University Teaching Hospital and by the Department of Dermatology and Infectious Diseases of Fréjus hospital and based on spontaneous reports submitted by general practitioners in private practice. RESULTS: We collected 54 reports of cases of syphilis: 37 in the Alpes-Maritimes region and 17 in the eastern Var region. The epidemic chiefly affected men since 44 of the 54 cases reported (81%) concerned males. 70% of these men were contaminated during homosexual contact (31 patients). In the majority of cases, contamination concerned local subjects. 50% of the patients in the study were infected with human immunodeficiency virus (HIV). The clinical forms observed were distributed as follows: 12 primary syphilis, 28 secondary syphilis, 13 latent syphilis, 1 case not specified. There was no difference in terms of clinical form between patients with and without HIV. DISCUSSION: Syphilis, which had become rare in France as a whole and in our region in particular, reappeared in the form of an epidemic in the Côte d'Azur region after first resurfacing in the Paris region. This outbreak principally affected homosexual and bisexual male patients, half of whom were HIV-positive. Screening for syphilis, potentially latent, should thus be carried out routinely during initial assessment and at subsequent monitoring of HIV patients.

Severe relapsing erysipelas associated with chronic Streptococcus agalactiae vaginal colonization.

We report a case of severe recurrent erysipelas of the breast due to infection with Streptococcus agalactiae and demonstrate that strains isolated from the skin were closely related to strains isolated from the vagina, which is consistent with the claim that the vagina acts as a reservoir for S. agalactiae isolates that are responsible for erysipelas relapse. Hypervirulence of strains and persistence of a bacterial reservoir may explain why 5 months of prophylaxis with penicillin V (1 million U daily) was necessary to achieve permanent eradication of vaginal carriage and to prevent recurrence of erysipelas caused by S. agalactiae infection.

[Relapse of Plasmodium falciparum malaria in a patient treated with artesunate]. / Rechute d'un paludisme à Plasmodium falciparum après un traitement par artésunate.

Chemoprophylaxis and the curative treatment of malaria are well documented in France. Nevertheless this data is still not accounted for by healthcare professionals and in the global population, and no longer approved treatments may be prescribed. The authors report the case of a 24-year-old female traveler having stayed in Africa where she was used to treat fever with artesunate. Soon after her return, she presented with uncomplicated Plasmodium falciparum malaria once again treated with artesunate. The evolution was initially favorable but a relapse occurred 3 weeks later. A conventional mefloquine treatment lead to a final cure. This observation confirms that artesunate monotherapy in malaria exposes to a risk of relapse. Artesunate should not be used as monotherapy in P. falciparum malaria.

Emergence of two populations of methicillin-resistant Staphylococcus aureus with distinct epidemiological, clinical and biological features, isolated from patients with community-acquired skin infections.

BACKGROUND: Community-acquired skin and soft-tissue infections due to methicillin-resistant Staphylococcus aureus (MRSA) are an emerging clinical and epidemiological problem. OBJECTIVES: To characterize community-acquired skin infections caused by S. aureus, and especially MRSA. METHODS: From November 1999 to December 2003, we conducted in a French hospital a prospective epidemiological, clinical and bacteriological study of skin infections acquired in the community, applying strict criteria for true community-acquired MRSA (CA-MRSA) and health-care-associated MRSA (HCA-MRSA). RESULTS: One hundred and ninety-seven patients had 207 skin infections (154 primary and 53 secondary infections). Twenty-two (11%) patients had skin infections caused by MRSA. The incidence of MRSA skin infections acquired in the community rose from 4% in 2000 to 17% in 2003, but the increase was not statistically significant. Six patients (3%) were infected by CA-MRSA and 15 (8%) by HCA-MRSA; one patient was lost to follow-up and could not be classified. CA-MRSA and HCA-MRSA had different epidemiological, clinical and biological characteristics. CA-MRSA infections were more severe than HCA-MRSA infections: all the CA-MRSA infections (six of six, 100%) required surgical treatment, compared with only two (15%) of 13 with HCA-MRSA infection (P < 0.001). CA-MRSA all belonged to the same clonal strain, harbouring an agr type 3 allele and the Panton-Valentine leucocidin genes (not detected in HCA-MRSA) and possessing a specific antibiotype. CONCLUSIONS: Two populations of MRSA causing skin infections are emerging in the French community, with distinct epidemiological, clinical and biological characteristics.

Skin manifestations of West Nile virus infection.

West Nile virus (WNV) infection is a potentially lethal arbovirus infection. Many notable outbreaks have occurred during the last few years throughout the world, including Europe and the USA. The severity of the disease is mainly related to the neurological complications. A maculopapular exanthema is reported as a clinical sign of the disease. Recently an outbreak of WNV infection occurred in southern France. Three patients out of 6 had a similar skin roseola-like eruption. The cluster of 3 cases of similar febrile roseola of unexplained cause during the same week led to the diagnosis of the first WNV human outbreak in France for 40 years.

In the era of highly active antiretroviral therapy, why are HIV-infected patients still admitted to hospital for an inaugural opportunistic infection?

OBJECTIVES: To identify factors related to delayed testing, and delayed or interrupted care-seeking or treatment uptake, among HIV-infected patients. DESIGN: HIV-infected patients hospitalized for an opportunistic infection (OI) cases were included in a prospective study and compared with controls matched by age and sex who had regular follow-up and treatment. Patients were asked to complete a questionnaire about their therapeutic itinerary and their socioeconomic, psychological and medical characteristics. RESULTS: Seventy patients were matched with 140 controls. According to their therapeutic itinerary prior to admission, cases were subdivided into four groups among which three will be more particularly studied: nontested patients (NT) (24%; n=17), known HIV-infected patients with no medical follow-up (NF) (30%; n=21); and noncompliant patients (NC) (36%, n=25). Characteristics of NT and NF patients included a predominantly sexual mode of contamination (P=0.01), continuing occupational activity (P=0.01) despite a low mean Karnofsky index (P=0.001) and unfavourable virological and immunological parameters. NT patients displayed a low degree of anxiety, and lacked awareness concerning risk of contamination and HIV-related symptoms. HIV-status announcement (P=0.04) and the benefits of medical follow-up (P=0.05) were less favourably perceived by NF patients than by controls, and were associated with a high degree of anxiety in NF patients. NC patients had a weaker commitment to follow-up and treatment, and more frequent treatment discontinuation associated with a higher rate of interruption of follow-up in a context of social difficulties. CONCLUSIONS: Patients ignorant of their HIV status, patients NF and NC have very specific characteristics. More appropriate approaches are needed regarding screening and access to care in order to reduce the incidence of delayed care-seeking.

Predictors of plasma human immunodeficiency virus type 1 RNA control after discontinuation of highly active antiretroviral therapy initiated at acute infection combined with structured treatment interruptions and immune-based therapies.

Thirty patients with acute human immunodeficiency virus (HIV) type 1 infection received a combination of 3 antiretroviral drugs (n=15) or 4 antiretroviral drugs plus hydroxyurea and interleukin-2 (n=15) for 24 months, followed by 1-3 structured therapeutic interruptions (STIs). Viral control, defined as maintaining plasma viremia <5000 copies/mL without therapy, was achieved in 14 cases. Lymphocyte subsets, plasma HIV-1 RNA loads, proviral DNA loads in peripheral blood mononuclear cells (PBMCs), residual HIV-1 RNA loads in PBMCs and in lymph node cells, and anti-p24 lymphoproliferative response were measured. In the multivariate analysis, proviral DNA loads in PBMCs and anti-p24 lymphoproliferative response assessed at 24 months were independently correlated with viral control after STI. These results enabled us to define a subgroup of patients for whom safe discontinuation of therapy initiated at acute infection was suitable and contributed to ascertaining priority for biological parameter assessment in future clinical trials.

[Confirmation of Leishmania infantum MON-24, agent of cutaneous leishmaniasis in southern France]. / Confirmation de Leishmania infantum MON-24, agent de leishmaniose cutanée dans le sud-est de la France.

Leishmania infantum MON-24, an agent causing cutaneous leishmaniasis, has only been reported once in Southern France. The authors report an additional case which confirms the presence of this zymodeme as agent of cutaneous leishmaniasis in this area. Treatment with a single course of liposomal amphotericine B did not show convincing efficacy.

Overexpression of Fas/CD95 and Fas-induced apoptosis in a patient with idiopathic CD4+ T lymphocytopenia.

The mechanisms of apoptosis have become better understood, in part with the discovery of Fas/CD95. We report the case of a patient characterized by a decreased CD4+ T cell count and an overexpression of Fas/CD95 resulting in apoptosis. A 54-year-old man presented with disseminated Mycobacterium xenopi infection. Analysis showed CD4+ T lymphopenia. Tests for human immunodeficiency virus (HIV) types 1 and 2 were negative. We compared the patient with eight healthy controls and five HIV-infected patients in terms of the expression of Fas/CD95 and Fas-mediated apoptosis of peripheral T lymphocytes. The percent of CD95+ cells in lymphocytes was 98% for the patient, and the mean percent of CD95+ cells in lymphocytes +/- SD for HIV-infected patients and healthy controls was 75% +/- 16% and 36% +/- 26%, respectively. The patient had a high level of spontaneous apoptosis, and apoptotic cells were all identified as being CD4+ T cells. Monoclonal antibodies to CD95 dramatically increased apoptosis of CD4+ T cells exclusively. CD4+ T lymphopenia observed in our patient correlated with an overexpression of Fas together with spontaneous and Fas-induced apoptosis.