Prise en charge d'une mucormycose disséminée chez un patient polytraumatisé et brûlé: intérêt des instillations locales, rapport de cas et revue de la littérature.

Mucormycosis are infrequent filamentous fungal infections, but severe and with high mortality (20 to 50%). Symptoms are very common, like necrosis, and burn/polytrauma patients have a higher risk of mucormycosis than the general population. We report here the history of a 38-year-old man, polytraumatized and burned because of a tractor incident. During the first two weeks two haemorrhagic shock episodes occurred because of necrosis of the humeral artery. Analysis of vascular fragment identified Lichteimia spp. The diagnosis of invasive infection was established after identifying Lichteimia spp. in blood cultures also. We treated the patient with intravenous liposomal amphotericin, oral posaconazole and surgical debridement according to the gold standard. The wound mucormycosis was also treated with a humeral bypass with vascular allograft and a latissimus dorsi pedicled flap. Furthermore, mucormycosis was treated with local instillations of amphotericin B in the dressings twice a day with 1% (1 mg/100mL) solution of non-liposomal amphotericin. Early diagnosis and treatment is very important for mucormycosis healing and to minimize morbimortality. With burn and polytrauma patients necrosis and bad local evolution have to be carefully screened and analyzed.

Satisfaction with sexual life in people living with HIV/AIDS: the persistent weight of the fear of transmission.

Sexual life is an important dimension of quality of life, which may be affected by the fear of transmission in people living with HIV/AIDS (PLWHA), despite the fact that antiretroviral therapy prevents person-to-person transmission. We, therefore, aimed to explore the sexual life satisfaction of PLWHA and its correlation with their fear of HIV transmission and self-esteem. Consecutive adult PLWHA from seven HIV care facilities in the Rhone-Alpes region, France, were asked to complete a self-administered, anonymous questionnaire concerning sociological and medical data, satisfaction with sexual life (18 questions), and self-esteem (Rosenberg score). Overall, 690 PLWHA answered the questionnaire (mean age 49.2 ± 11 years); 74.9% were men, of which 75.1% had sex with men. Overall, 68.0% of respondents feared transmitting HIV (a lot/a bit). A lower satisfaction with sexual life was significantly associated with being female, not having a stable sexual partner, being unemployed, having a low income, experiencing a fear of HIV transmission, having lower self-esteem, and not reporting an excellent/very good health status. These results strongly suggest that the information concerning the antiretroviral-induced suppression of infectivity should be widely diffused, as this may enhance the quality of sexual life in PLWHA.

Non-compliance with IDSA guidelines for patients presenting with methicillin-susceptible Staphylococcus aureus prosthetic joint infection is a risk factor for treatment failure.

OBJECTIVE: The long-term impact of treatment strategies proposed by the IDSA guidelines for patients presenting with methicillin-susceptible S. aureus (MSSA) prosthetic joint infection (PJI) is not well-known. PATIENTS AND METHODS: Retrospective (2000-2010) cohort study including patients presenting with MSSA hip or knee PJI. A univariate Cox analysis was performed to determine if the non-compliance with IDSA surgical guidelines was a risk factor for treatment failure. RESULTS: Eighty-nine patients with a mean follow-up of 2.8 years were included. Non-compliance with IDSA surgical guidelines was associated with treatment failure (hazard ratio 2.157; 95% CI [1.022-4.7]). The American Society of Anesthesiologists score, inadequate antimicrobial therapy, and a rifampicin-based regimen did not significantly influence patient outcome. CONCLUSION: Based on the IDSA guidelines, if a patient presenting with MSSA PJI is not eligible for implant retention, complete implant removal is needed to limit treatment failure.

[Chronic necrotizing pulmonary aspergillosis following an infection by Mycobacterium malmoense]. / Aspergillose pulmonaire chronique nécrosante compliquant une pneumopathie à Mycobacterium malmoense.

Pneumonia due to Mycobacterium malmoense is rare and usually occurs in damaged lung as is the case with Aspergillus infections. We report the case of a patient who developed chronic necrotizing pulmonary aspergillosis following an infection by atypical mycobacteria. A 53-year-old woman was hospitalized because of weight loss and fever. Direct examination of sputum smear was positive for acid fast bacilli and PCR and culture led to the diagnosis of infection with M. malmoense. Treatment was begun with clarithromycin, rifampicin and ethambutol. Despite initial improvement and excellent adherence to treatment, fever and weight loss recurred 6 months later. Relapse of the mycobacterial infection was excluded and the final diagnosis was necrotizing pulmonary aspergillosis. Infection with A. fumigatus complicating the treatment of M. malmoense is unusual. The management is challenging because of strong interactions between voriconazole and rifampicin, and thus requires a multidisciplinary and specialized approach.

[Influenza A H1N1 in neonatal intensive care unit: analysis and lessons]. / Grippe A H1N1 en unité de néonatologie : analyse et enseignements.

Since WHO announced the flu-like pandemic H1N1v in autumn 2009, data on clinical presentation and treatment of H1N1v infection in preterm infants with oseltamivir remain scarce. We cared for four infected preterm infants and ordered prophylactic treatment with oseltamivir in 13 additional contact preterm infants. A number of lessons can be drawn from this experience. The first two cases in twins were revealed by an increase in the number of apnea and one infant required mechanical ventilation. Cough was the major symptom in the two other infected infants. No digestive intolerance was observed among the 17 preterm infants during oseltamivir treatment. Polymerase chain reaction (PCR) quickly determined whether an infant was infected, making it helpful in deciding on initial containment. PCR remained positive, whereas culture became negative. Therefore, culture appeared to be more relevant in deciding on the end of containment. Follow-up of the four infected infants showed their ability to develop immunity against H1N1v.

Proficiency of transient elastography compared to liver biopsy for the assessment of fibrosis in HIV/HBV-coinfected patients.

Transient elastography (TE) is a noninvasive technique to evaluate liver fibrosis. We compared the performance of TE with liver biopsy (LB) in patients with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection. Patients prospectively underwent TE and LB. The diagnosis accuracy of TE was calculated using receiver operating characteristic (ROC) curves for different stages of fibrosis, and optimal cut-off values were defined. A sequential algorithm combining TE with biochemical score (Fibrotest) is proposed. Fifty-seven patients had both TE and LB (median time: 3 days) and two with proven cirrhosis, only TE. Forty-six (78%) were under antiretroviral therapy with anti-HBV drugs in 98%, and 19 (32%) had elevated alanine aminotransferase (ALT). A significant correlation was observed between liver stiffness measurement (LSM) and METAVIR fibrosis stages (P < 0.0001). Patients with elevated ALT tended to have higher LSM than those with normal ALT. The areas under the ROC curves were 0.85 for significant fibrosis (≥ F2), 0.92 for advanced fibrosis (≥ F3) and 0.96 for cirrhosis. Using a cut-off of 5.9 kPa for F ≥ 2 and 7.6 kPa for F ≥ 3, the diagnosis accuracy was 83% and 86%, respectively. With an algorithm combining TE and Fibrotest, 97% of patients were well classified for significant fibrosis. Using this algorithm, the need for LB can be reduced by 67%. In HIV/HBV-coinfected patients, most of them with normal ALT under antiretroviral treatment including HBV active drugs, TE was proficient in discriminating moderate to severe fibrosis from minimal liver disease.

Clostridium sordellii brain abscess diagnosed by 16S rRNA gene sequencing.

Clostridium sordellii is usually associated with skin and soft tissue infections. We describe the first case to our knowledge of a Clostridium sordellii-associated brain abscess, diagnosed by 16S rRNA gene sequencing, expanding the microbiological spectrum of brain abscesses, with emphasis on the role of 16S rRNA gene PCR in their etiologic diagnosis.

[Recurrent aseptic meningitis secondary to nonsteroidal anti-inflammatory drugs in a patient with lupus]. / Méningite aseptique récidivante due aux anti-inflammatoires non stéroïdiens chez une patiente lupique.

We report a 39-year-old woman with systemic lupus who presented with recurrent aseptic meningitis secondary to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). She presented two episodes following ibuprofen administration that were characterized by aseptic meningitis with high protein level in cerebrospinal fluid, and increased serum acute phase reactants. No evidence of an infection or vasculitis was documented. Clinical manifestation resolved rapidly with ibuprofen discontinuation, and corticosteroids therapy was unnecessary. Aseptic meningitis related to NSAIDs reported in lupus patients should be considered because of their specific modality of care and their favourable outcome.

[Spinal cord toxoplasmosis in HIV infection]. / Toxoplasmose médullaire au cours de l'infection à VIH.

We report the case of an atypical localization of a spinal cord "toxoplasmic abscess". The 46-year-old patient, HIV-1 positive, was admitted for acute urine retention and gait disorders. MRI revealed a T12-L1 medullary lesion suggesting a tumoral, inflammatory and infectious pathology. The radiological aspect and immunosuppression lead to the initiation of a treatment against Toxoplasma gondii, following the same treatment principles as for cerebral toxoplasmosis. The diagnosis can only be proved by data from autopsy or surgical biopsy, but toxoplasmosis PCR on CSF seems to be an interesting alternative to confirm the diagnosis. According to the literature, PCR is not sensitive enough as a diagnostic tool. Improvement after treatment supported the diagnosis confirmed by PCR.

Disseminated nontuberculous infections with Mycobacterium genavense during sarcoidosis.

Sarcoidosis is a chronic disease characterised by the development and accumulation of granulomas in multiple organs. We report two observations of disseminated Mycobacterium genavense infection in patients with proven sarcoidosis. High fever and abdominal pain appeared at 8 and 18 months following the initiation of immunosuppressive therapy. Abdominal computed tomography scans of the patients showed diffuse mesenteric lymphadenitis and splenomegaly. The diagnosis was obtained on bone marrow specimens for both patients with numerous acid-fast bacteria at direct examination and positive specific mycobacterial identification by nucleic acid amplification test. Despite prompt antimycobacterial therapy, occurrence of complications (peritonitis post-splenectomy surgery and lung carcinoma) resulted in a fatal outcome for both patients. These cases highlight that opportunistic infections like M. genavense or other nontuberculous mycobacterial infections should be considered for long-standing immunocompromised patients with sarcoidosis.

Diffusion-weighted imaging in brain aspergillosis.

Brain aspergillosis is a rare pathology, occurring mainly in immunocompromised patients, responsible for multiple cerebral septic infarctions. Some researchers have described magnetic resonance (MR) findings in cerebral invasive aspergillosis, but diffusion-weighted imaging (DWI) has rarely been reported, especially in typical non-enhancing lesions, while it may be helpful for early differential diagnosis and may allow earlier antifungal treatment. We describe three cases of patients presenting brain aspergillosis, with MR imaging including diffusion-weighted sequences and apparent diffusion coefficient (ADC) cartography. The three patients described in this study presented a total of 23 circular lesions, and one patient presented an infarction area in the territory of the right middle cerebral artery. Lesions were ring-enhancing for one patient, and presented no enhancement for the other two. Eleven lesions were very bright on DWI, with reduced ADC values. Twelve lesions, either enhancing or not enhancing, presented a 'target-like' aspect with central and peripheral hypointense areas on DWI, corresponding to higher ADC value areas, and intermediate marked hypersignal on DWI. This typical aspect of aspergillosis lesions on DWI may allow early diagnosis and treatment of cerebral aspergillosis, and is helpful for differentiating aspergillosis lesions from other infectious or malignant lesions affecting immunocompromised patients.

[Vaccination against influenza: results of a study on vaccination coverage among health care workers in the Croix-Rousse Hospital (Hospitals of Lyon)]. / Vaccination contre la grippe: résultats d'une enquête sur la couverture vaccinale du personnel hospitalier à l'hôpital de la Croix-Rousse (hôpitaux de Lyon).

INTRODUCTION: The aim of this study was to evaluate the vaccinal status among Croix-Rousse Hospital workers, attitude towards this vaccination, and the information delivered in order to promote this vaccination. METHODS: Questionnaires were delivered by electronic mailing. RESULTS: Six hundred (and) twenty-nine questionnaires were analyzed (26.7% of hospital workers); 30.7% of responders were vaccinated against influenza, 89.2% of responders were aware of influenza and vaccine. Vaccine coverage was lower in younger workers, non health-care workers, non physician health-care workers, and surgeons who responded. Motivation and reserve varied according to the status, position, and age, with some discrepancies. CONCLUSION: These results suggest implementing a better targeted vaccination campaign, according to the various categories of personnel.

[Lemierre syndrome variant: Hepatic abscesses and hepatic venous thrombosis due to Fusobacterium nucleatum septicemia]. / Un variant du syndrome de Lemierre: abcès hépatiques et thrombose veineuse sus-hépatique secondaire à une septicémie à Fusobacterium nucleatum.

INTRODUCTION: Like Fusobacterium necrophorum, Fusobacterium nucleatum is capable causing Lemierre's syndrome. Various locations of venous thrombosis have been described associated with Fusobacterium sp. septicemia. EXEGESIS: We describe a 43-year old alcoholic patient with F.nucleatum septicemia complicated with hepatic abscesses, middle hepatic venous thrombosis, osteomyelitis and infiltrative pneumonia. A pancreatic prosthesis was the only potentially identified infectious entrance. CONCLUSION: Our patient showed an alternative presentation of Lemierre's syndrome, a "digestive variant". To the best of our knowledge, this is the first report of Fusobacterium septicemia associated with hepatic venous thrombosis. This report is close to the cases of portal thrombosis and opens the clinical sphere of the lemierre's syndrome, whose incidence is increasing.

[Treatment interruption in HIV infected patients: clinical and biological evolution]. / Interruption thérapeutique chez des patients infectés par le virus de l'immunodéficience humaine: évolution clinique et biologique.

OBJECTIVE: The authors had for aim to evaluate the clinical and biological evolution in HIV-infected patients with viraemia lower than 30,000 copies/mL having decided to interrupt their treatment. PATIENTS AND METHODS: Patients with highly active antiretroviral therapy (HAART) for more than 3 months followed by treatment interruption longer than 1 month were included in a retrospective analysis. RESULTS: Forty-six patients having stopped treatment between November 1999 and July 2003 were included. The median duration of treatment interruption was 9.5 months. During the study, no clinical event occurred for 21 patients, and at least 1 clinical event occurred for the 25 others. The median CD4(+) cell counts (CD4) before and at the end of treatment interruption were 597/mm(3) and 437/mm(3), respectively (P<0.001). The median values of viral load before and at the end of treatment interruption were <50 and 23749 copies/mL, respectively (P<0.001). Among the 26 patients having started a new HAART, pre-treatment interruption and post-new HAART median CD4 (with a median delay after HAART of 9.7 months) were 548 and 432.5/mm(3) (P=0.02). Pre-treatment interruption and post-new HAART median viral load were 131.5 and 94.5 copies/mL (NS). CONCLUSIONS: Treatment interruption must be used with caution in spite of the absence of virological impact, because CD4 cell count after new HAART is lower than CD4 preceding treatment interruption. Treatment interruption is contraindicated for patients with AIDS. Physicians must carefully follow other patients who decide on a treatment interruption.

Possibly linezolid-induced peripheral and central neurotoxicity: report of four cases.

BACKGROUND: Linezolid is the first member of the new synthetic class of antibacterial agents that prevent the formation of the 70S ribosomal subunit. It represents an attractive choice in the therapeutic arsenal because it is effective against methicillin-resistant strains of Staphylococcus spp. Adverse hematological events have been reported. They are rapidly reversible after discontinuation of treatment and usually occur during treatment courses of more than 2 weeks. The advised duration of linezolid use is 28 days and the consequences of prolonged use are unknown. In addition, this drug has some dopaminergic properties that can induce the serotonin syndrome if a monoamine oxidase inhibitor is used simultaneously. PATIENTS AND METHODS: Since linezolid became available for use in 2002, four cases of probable central and peripheral linezolid-induced neurotoxicity have been recorded in our unit. RESULTS: Two de novo peripheral neuropathies and one worsening of a preexisting toxic neuropathy have been observed. In each case, linezolid therapy was used during a prolonged duration of 8, 23, and 24 weeks, respectively. First neurological signs appeared in one case during the 2nd week of treatment and beyond the 1st month in the other cases. To date, all cases of peripheral neuropathy resulted in persistent neurological damage after discontinuation of linezolid. Assessments did not reveal any other explanation for these neurological impairments. Another case concerned a patient who developed transient encephalopathy attributed to linezolid during a coadministration with hydroxyzine. CONCLUSION: Linezolid may induce persistent peripheral neuropathy after prolonged use and may cause a transient central neurotoxicity in combination with an anticholinergic agent, such as an antihistamine. Close neurological monitoring should be recommended in prolonged linezolid therapy and coadministration of a serotonin reuptake inhibitor or antihistamine should be avoided to limit neurological adverse events.

[Tuberculoma and tuberculous meningeal-radiculitis with paradoxical progression during treatment]. / Tuberculomes et méningoradiculite tuberculeuse d'évolution paradoxale sous traitement.

INTRODUCTION: Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare. OBSERVATION: An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy. DISCUSSION: During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.

[Factitious disorder revealed by polymicrobial septic arthritis of a lumbar facet joint diagnosed by percutaneous biopsy]. / Pathomimie révélée par une arthrite septique interapophysaire postérieure polymicrobienne: diagnostic par biopsie percutanée.

Septic arthritis of a lumbar facet joint is rare with few reports in the literature. Clinically, septic arthritis of a lumbar facet joint can mimic spondylodiscitis. Imaging is usually required for diagnosis. Bacteriological diagnosis is needed to optimize treatment with antibiotics. Most of the previously reported cases were due to staphylococcus aureus. We report one case due to rare bacteria which lead to a diagnosis of factitious disorder. Precise bacteriological diagnosis was obtained by CT-guided percutaneous biopsy.