Chikungunya virus-associated encephalitis: A cohort study on La Réunion Island, 2005-2009.

OBJECTIVE: To estimate the cumulative incidence rate (CIR) of Chikungunya virus (CHIKV)-associated CNS disease during the La Réunion outbreak, and assess the disease burden and patient outcome after 3 years. METHODS: CHIKV-associated CNS disease was characterized retrospectively in a cohort of patients with positive CHIKV reverse transcriptase PCR or anti-CHIKV immunoglobulin M antibodies in the CSF and fulfilling International Encephalitis Consortium criteria for encephalitis or encephalopathy. Neurologic sequelae were assessed after 3 years. RESULTS: Between September 2005 and June 2006, 57 patients were diagnosed with CHIKV-associated CNS disease, including 24 with CHIKV-associated encephalitis, the latter corresponding to a CIR of 8.6 per 100,000 persons. Patients with encephalitis were observed at both extremes of age categories. CIR per 100,000 persons were 187 and 37 in patients below 1 year and over 65 years, respectively, both far superior to those of cumulated causes of encephalitis in the United States in these age categories. The case-fatality rate of CHIKV-associated encephalitis was 16.6% and the proportion of children discharged with persistent disabilities estimated between 30% and 45%. Beyond the neonatal period, the clinical presentation and outcomes were less severe in infants than in adults. CONCLUSIONS: In the context of a large outbreak, CHIKV is a significant cause of CNS disease. As with other etiologies, CHIKV-associated encephalitis case distribution by age follows a U-shaped parabolic curve.

Chikungunya virus-associated long-term arthralgia: a 36-month prospective longitudinal study.

BACKGROUND: Arthritogenic alphaviruses, including Chikungunya virus (CHIKV), are responsible for acute fever and arthralgia, but can also lead to chronic symptoms. In 2006, a Chikungunya outbreak occurred in La Réunion Island, during which we constituted a prospective cohort of viremic patients (n = 180) and defined the clinical and biological features of acute infection. Individuals were followed as part of a longitudinal study to investigate in details the long-term outcome of Chikungunya. METHODOLOGY/PRINCIPAL FINDINGS: Patients were submitted to clinical investigations 4, 6, 14 and 36 months after presentation with acute CHIKV infection. At 36 months, 22 patients with arthralgia and 20 patients without arthralgia were randomly selected from the cohort and consented for blood sampling. During the 3 years following acute infection, 60% of patients had experienced symptoms of arthralgia, with most reporting episodic relapse and recovery periods. Long-term arthralgias were typically polyarthralgia (70%), that were usually symmetrical (90%) and highly incapacitating (77%). They were often associated with local swelling (63%), asthenia (77%) or depression (56%). The age over 35 years and the presence of arthralgia 4 months after the disease onset are risk factors of long-term arthralgia. Patients with long-term arthralgia did not display biological markers typically found in autoimmune or rheumatoid diseases. These data helped define the features of CHIKV-associated chronic arthralgia and permitted an estimation of the economic burden associated with arthralgia. CONCLUSIONS/SIGNIFICANCE: This study demonstrates that chronic arthralgia is a frequent complication of acute Chikungunya disease and suggests that it results from a local rather than systemic inflammation.

[Outbreak of influenza pandemic virus A(H1N1) 2009 infections in Emergency Department, Saint-Pierre, Reunion Island. July-August 2009]. / Prise en charge dans un service d'urgence de l'épidémie à virus pandémique A(H1N1) 2009 à Saint-Pierre, île de La Réunion. Juillet-Août 2009.

INTRODUCTION: The 2009 pandemic influenza A (H1N1) virus has emerged to cause the first pandemic of the 21st century. On July 3, 2009, novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in Reunion Island, French overseas department located in the southern hemisphere. The present study describes the characteristics and the impact of the epidemic on the activity of an emergency department (ED) from July 3 to August 31, 2009. METHOD: Patients consulting the ED with a discharge diagnosis of influenza-like illness were analyzed. RESULTS: The ED activity in 2009, compared to 2008, increased by 0.5% in July and 9.7% in August. In July and August, respectively 7.1 and 20.0% cases of S-OIV infection were hospitalized. For the 394 patients studied (186 males, 36.2+/-18.5 years), 199 (50.5%) were reported to have comorbidity or risk factor (RF) for complications. Complications occurred in 112 patients (28.4%). The most common complications were bronchospasme (52.7%), pneumonia (32.1%), decompensation caused by comorbidity (17.9%). Seventy-three patients (18.5%) required hospitalization. Patients aged 65 and over accounted for 10.9% of all patients, 31.5% of hospitalized patients and 21.4% of complicated S-OIV infection. Regardless of age, comorbidity and / or RF was reported in 80.2% of complicated S-OIV infection and 86.3% of hospitalized patients. The circuit of patients with S-OIV infection was initially focused on "consultation S-OIV" localized in ED. This organization mobilized several health professionals, disorganized the various medical departments involved, and was unsuitable for the childcare or patient's monitoring with signs of poor tolerance. This organization, even identifying S-OIV patients at their arrival, referred patients to different areas of the hospital and various consultation rooms in ED. CONCLUSION: Recommendations for surveillance, prevention and policy for persons with RF, particularly respiratory disease, are justified. This feedback can raise questions about the patient's circulation in hospital and adjust plans for the organization.

Prospective study of Chikungunya virus acute infection in the Island of La Réunion during the 2005-2006 outbreak.

BACKGROUND: Chikungunya virus (CHIKV) is a recently re-emerged arthropod borne virus responsible for a massive outbreak in the Indian Ocean and India, and extended to Southeast Asia as well as Italy. CHIKV has adapted to Aedes albopictus, an anthropophilic mosquito species widely distributed in Asia, Europe, Africa and America. Our objective was to determine the clinical and biological features of patients at the acute phase of CHIKV infection. METHODS AND FINDINGS: A prospective study enrolled 274 consecutive patients with febrile arthralgia recorded at the Emergency Department of the Groupe Hospitalier Sud-Réunion between March and May 2006. Three groups were defined: one group of 180 viremic patients (positive CHIKV RT-PCR), one group of 34 patients with acute post-viremic infection (negative CHIKV RT-PCR, positive anti-CHIKV IgM and negative IgG), and one group of 46 uninfected patients (negative CHIKV RT-PCR, anti-CHIKV IgM and IgG). Bivariate analyses of clinical and biological features between groups were performed. Patients with CHIKV viremia presented typically with asymmetrical bilateral polyarthralgia (96.5%) affecting the lower (98%) and small joints (74.8%), as well as asthenia (88.6%), headache (70%), digestive trouble (63.3%), myalgia (59%), exanthems (47.8%), conjunctival hyperhemia (23%) and adenopathy (8.9%). Vertigo, cutaneous dysesthesia, pharyngitis and haemorrhages were seldom observed. So far unreported symptoms such as chondrocostal arthralgia (20%), entesopathies (1.6%), talalgia (14%) were also noted. Prurit was less frequent during the viremic than post-viremic phase (13.9% vs. 41.2%; p<0.001), whereas lymphopenia was more frequent (87.6% vs. 39.4%; p<0.001). Others biological abnormalities included leukopenia (38.3%), thrombocytopenia (37.3%), increased ASAT and ALAT blood levels (31.6 and 7.3%, respectively) and hypocalcemia (38.7%). Lymphopenia <1,000/mm(3) was very closely associated with viremic patients (Yule coefficient 0.82, positive predictive value 92.3%). Age under 65 was associated with a benign course, as no patients younger than 65 had to be hospitalized (Yule coefficient 0.78). CONCLUSIONS: The diagnosis of CHIKV infection in acute phase is based on commonly accepted clinical criteria (fever and arthralgia), however clinical and biological diffrences exist in acute phase depending on whether or not the patient is within the viremic phase of the infection.

[Stonefish stings: difficult analgesia and notable risk of complications]. / Piqûres par poisson-pierre: une antalgie difficile, un risque notable de complications.

INTRODUCTION: Marine activities and water sports in tropical countries entail some dangers. In our emergency department, stonefish (Synancae verrucosa) stings are second only to those by sea urchins among the 400 consultations a year for wounds by marine animals. METHOD: We retrospectively collected data for all emergency department visits for stonefish stings over a 5-year period from 2001 through 2005. RESULTS: The study included 57 patients (42 men; mean age 31.2+/-15.9 years, range 3-63 years) at 61 consultations. The reason for the emergency department visit was pain, often described as intense. Injuries occurred to the foot in 79% of cases and the hand in 21%. Local signs included a wound (100%), edema (74%), local inflammation (21%), bruising (23%), necrosis (19%), and, in one patient, cellulitis. Pain was reported in 95% of cases. Local care consisted of immersing the stung area in hot water (79%) or in situ lidocaine injection (16%). Analgesics were administered in 75% of the cases, including morphine (54%) and anti-inflammatory drugs in 47%. Other analgesic techniques included ketamine (3.5%), nitrous oxide (3.5%), and local or regional anesthesia (3.5%); 29% of patients received antibiotics. Patients requiring admission (46%) differed from those who did not by a need for more intense analgesia and by greater wound inflammation and necrosis. Three patients required surgery and three others, hyperbaric oxygen therapy. CONCLUSION: Stonefish stings present the risk of local complications. Analgesia is also a major concern for emergency physicians and prophylactic antibiotics must be considered.

Development of a sensitive real-time reverse transcriptase PCR assay with an internal control to detect and quantify chikungunya virus.

BACKGROUND: The chikungunya virus (CHIKV; Alphavirus, Togaviridae) has emerged in the south Western Indian Ocean since early 2005. A major outbreak of CHIKV infection occurred in Réunion Island, where the virus is transmitted by Aedes albopictus mosquitoes. Facing an outbreak of unprecedented magnitude, we developed a rapid, sensitive, and reliable assay for the detection and quantification of CHIKV in plasma samples. METHODS: A dual-color TaqMan 1-step reverse transcriptase PCR assay was developed in a LightCycler 2.0 system. A coextracted and coamplified chimerical RNA sequence was used as an internal control (IC) to eliminate false-negative results. The CHIKV-specific and IC probes were labeled with 6-carboxyfluorescein (530 nm) and the wide span dye DYXL (705 nm), respectively, eliminating the need for color compensation. A synthetic RNA was used as an external calibrator for CHIKV absolute quantification. RESULTS: The detection limit was 350 copies/mL (3 copies/capillary). A further improvement to approximately 40 copies/mL was obtained by use of a larger volume of plasma. The assay specificity was confirmed in vitro and in silico. CHIKV in 343 patients was present at viral loads >10(8) copies/mL, mainly in newborns and seniors >60 years old. Long viremic phases of up to 12 days were seen in 6 patients. CONCLUSIONS: The assay is rapid, CHIKV-specific, and highly sensitive, and it includes an IC. It proved useful to detect and quantify CHIKV during the Réunion Island epidemic. The assay might be applicable to other CHIKV epidemics, especially in the Indian subcontinent, where an extensive outbreak is ongoing.

Outbreak of chikungunya on Reunion Island: early clinical and laboratory features in 157 adult patients.

BACKGROUND: Chikungunya is a reemerging disease. In 2005-2006, a severe outbreak occurred on Reunion Island in the southwestern part of the Indian Ocean. Other islands in this area were affected during the same period. METHODS: Adult patients with acute chikungunya (defined as onset of fever and/or polyarthralgia in the 5 days preceding consultation) and laboratory-confirmed chikungunya who were referred to Groupe Hospitalier Sud Reunion during the period from March 2005 through April 2006 were included in this retrospective study. Their clinical and laboratory features are reported. RESULTS: Laboratory-confirmed acute chikungunya was documented in 157 patients. The mean age of patients was 57.9 years, and the ratio of male to female patients was 1.24 : 1. Sixty percent of patients had at least 1 comorbidity. Ninety-seven patients (61.8%) were hospitalized, and 60 (38.2%) were treated as outpatients. Five fatalities were reported. One hundred fifty-one patients (96.1%) experienced polyarthralgia, and 129 (89%) experienced fever. Gastrointestinal symptoms were reported by 74 patients (47.1%), and skin rash was reported by 63 (40.1%). Hemorrhagic signs were rare. Lymphopenia and hypocalcemia were the prominent laboratory findings. Severe thrombocytopenia was rarely observed. CONCLUSIONS: Chikungunya virus can be responsible for explosive outbreaks of disease. Polyarthralgia and fever are the 2 main clinical features. In this era of travel and globalization, chikungunya should be considered in the differential diagnosis of febrile polyarthralgia with an abrupt onset.

[Trends in the pharmaceutical profile of intentional drug overdoses seen in the emergency room]. / Evolution des médicaments utilisés dans les intoxications médicamenteuses volontaires examinées aux urgences.

OBJECTIVES: The aim of the study was to investigate trends in substances used for acute self-administered drug overdoses (SADO). METHOD: Review of all SADO emergency room visits over two 1-year periods during 1992-1993 (P1) and 2001-2002 (P2). RESULTS: We compared 804 SADO episodes in P1 with 830 in P2. Patient characteristics did not differ significantly during the two periods (predominance of women: 66 vs 69%; mean age: 33 +/- 12 vs 37 +/- 13.5 years). Psychotropic drugs predominated in both periods (78 and 77%), but the prevalence of benzodiazepines declined (67 to 55%; p < 0.01) and that of antidepressants increased (9.5 to 15%; p < 0.01). Bromazepam was the ben-zodiazepine used most often during both periods (P1: 30% and P2: 35%), but the use of aprazolam increased (from 6 to 17%; p < 0.01). Among the antidepressants, the use of tricyclics decreased (from 43 to 14%; p < 0.01) and that of selective serotonin reuptake inhibitors increased (31 to 71%; p < 0.01). The proportion of benzodiazepine-related drugs increased over time (8.1 to 14%: p < 0.01). The other therapeutic classes remained quite similar to each other between P1 and P2, except for anti-inflammatories (P1: 1.3%, P2: 2.7%; p = 0.01). Among the analgesics, paracetamol alone or combined with other agents predominated (68 and 64% respectively), but use of opiate analgesics was fre-quent during the later period (2.7 vs 22%; p < 0.01). CONCLUSION: The trend of the different pharmacological families used in SADO seen in the emergency room has not fundamentally changed over the past decade. However, qualitative changes within the drug classes require emergency physicians to update their knowledge of toxicology.

Change in profile of acute self drug-poisonings over a 10-year period.

All acute, deliberate, drug-poisoning-related emergency department visits over two periods of one year, 1992-1993 (P1) and 2001-2002 (P2), were reviewed to investigate trends in substances used for acute self drug-poisonings over a 10-year period. For P1 and P2 respectively, 804 and 830 episodes of acute self drug-poisonings were compared. For the two studied periods, psycholeptic drugs predominated (78 and 77%); however, benzodiazepines declined (67 to 55%; P <0.01) and antidepressants increased (9.5 to 15%; P <0.01). Moreover, the type of antidepressant changed markedly with a decrease of the imipraminic antidepressants (48.4 to 10.7%) and an increase of selective serotonin reuptake inhibitors (31.2 to 74%). The proportion of benzodiazepine-related drugs increased with time (7.9 to 14.1%). The proportion of analgesics was 5.4% for P1 and 7.3% for P2; paracetamol, alone or associated to other compounds, remained the most incriminated. Nevertheless, opioids were more often mentioned during the later period (11.6 to 24.5%). The trend of the different pharmacological families used in acute self drug-poisonings is not fundamentally different over a 10-year period. However, there are some qualitative modifications, which are important for readjusting the emergency physician's toxicological knowledge and public health actions.