Maintenance treatment of pemphigus with rituximab in real life: A single-center study of 50 patients.

BACKGROUND: Following the RITUX 3 therapeutic trial, the French national diagnosis and care protocol (NDCP) for the treatment of pemphigus was updated in 2018. The updated protocol recommends initial treatment with rituximab (RTX) followed by maintenance therapy at 12 and 18 months, and potentially at 6 months where there are risk factors for early relapse. We evaluated these recommendations regarding the management of our own patients. PATIENTS AND METHODS: Our single-center retrospective study included all patients with pemphigus diagnosed between 01/2015 and 10/2020 and receiving at least one initial infusion of RTX. We collected the following data: type of pemphigus, severity, levels of anti-desmoglein 1 and 3 antibodies at diagnosis and between 2 and 6 months after initial RTX, presence or absence of maintenance therapy and modalities, time to first relapse and duration of associated systemic corticosteroid therapy ≥5 mg/day. Maintenance treatment modalities were as follows: no maintenance treatment, maintenance "on demand" (MT1) i.e. not performed at the rate imposed by the NDCP, and maintenance "according to NDCP" (MT2). RESULTS: Fifty patients were included (women 54%, median age 58 years, pemphigus vulgaris 68%, moderate to severe 68%). Initial RTX was combined with systemic corticosteroid therapy at 0.5 to 1 mg/kg in 74% of cases. Twenty-seven patients (54%) received no maintenance therapy, 13 were on an MT1 regimen (26%), and 10 were on an MT2 regimen (20%). Median follow-up was 42 months. At the last follow-up, 39 patients (78%) were in complete remission. A total of 25 patients (50%) relapsed: 18/27 (67%) patients without maintenance, 5/13 (38%) with MT1, and 2/10 (20%) with MT2 (p = 0.026). The probability of relapse over time was significantly lower in patients receiving maintenance therapy compared to those who receiving none (p = 0.022). The median time to relapse was 15 months in patients without maintenance, and 30 and 28 in those with maintenance (p = 0.27). The median duration of systemic corticosteroid therapy ≥ 5 mg/day in the no-maintenance group was 10 months, compared to 7 and 9 months respectively in MT1 and MT2 (p = 0.91). CONCLUSION: Our study confirms the value of RTX maintenance therapy in pemphigus in real life.

Impact of systemic to topical steroids switch on the outcome of drug reaction with eosinophilia and systemic symptoms (DRESS): A monocenter retrospective study of 20 cases.

BACKGROUND: There is no consensus on the treatment of drug reaction with eosinophilia and systemic symptoms (DRESS). At our center, systemic steroids (SS) are used for severe cases while topical steroids (TS) are used for mild and moderate forms. OBJECTIVES: To investigate the short-term outcome for patients with DRESS receiving SS as first-line therapy before being transferred to our department and then switched to TS after admission. METHODS: A retrospective monocenter study in DRESS patients (RegiSCAR score≥4) transferred to our dermatology department from a different setting between 07/2012 and 06/2018 and who had received SS before being transferred. Epidemiological, clinical and laboratory data were collected, as well as details of treatment modalities and outcome. RESULTS: Twenty patients were included. On admission to our department, 4 were assessed as having severe DRESS and continued on SS, while 16 were assessed as mild/moderate DRESS and were switched to TS. Among these 16 patients, the outcome on TS was favorable for 12 and quickly unfavorable for 4, who had to be switched back to SS. Retrospective analysis of the initial data (before transfer) showed that these 4 patients had previously had a greater number of severity criteria than the other 12. CONCLUSION: Caution is needed not only when deciding to initiate SS in DRESS but also on withdrawal of these drugs. Our series suggests that when SS are used as first-line therapy in DRESS patients with initial severity criteria, they should not be withdrawn quickly for a switch to TS, even where progression appears favorable, due to the risk of relapse.

Towards a better understanding of adult idiopathic epidermal necrolysis: a retrospective study of 19 cases.

BACKGROUND: Most cases of Stevens-Johnson syndrome and toxic epidermal necrolysis are drug-induced. A small subset of cases remain with unknown aetiology (idiopathic epidermal necrolysis [IEN]). OBJECTIVE: We sought to better describe adult IEN and understand the aetiology. METHODS: This retrospective study was conducted in 4 centres of the French national reference centre for epidermal necrolysis. Clinical data were collected for the 19 adults hospitalized for IEN between January 2015 and December 2019. Wide toxicology analysis of blood samples was performed. Histology of IEN cases was compared with blinding to skin biopsies of drug-induced EN (DIEN, 'controls'). Available baseline skin biopsies were analysed by shotgun metagenomics and transcriptomics and compared to controls. RESULTS: IEN cases represented 15.6% of all EN cases in these centres. The median age of patients was 38 (range 16-51) years; 68.4% were women. Overall, 63.2% (n = 12) of cases required intensive care unit admission and 15.8% (n = 3) died at the acute phase. Histology showed the same patterns of early- to late-stage EN with no difference between DIEN and IEN cases. One toxicology analysis showed unexpected traces of carbamazepine; results for other cases were negative. Metagenomics analysis revealed no unexpected pathological microorganism. Transcriptomic analysis highlighted a different pro-apoptotic pathway in IEN compared to DIEN, with an overexpression of apoptosis effectors TWEAK/TRAIL. CONCLUSIONS: IEN affects young people and is a severe form of EN. A large toxicologic investigation is warranted. Different pathways seem involved in IEN and DIEN, leading to the same apoptotic effect, but the primary trigger remains unknown.

Cross-reactivity in beta-lactams after a non-immediate cutaneous adverse reaction: experience of a reference centre for toxic bullous diseases and severe cutaneous adverse reactions.

BACKGROUND: Cross-reactivity among beta-lactam antibiotics (BL) is essentially reported in immediate hypersensitivity. OBJECTIVES: To evaluate cross-reactivity beyond BLs in patients with non-immediate cutaneous adverse drug reaction (non-immediate CADR) managed in a dermatology reference centre of toxic bullous and severe CADRs. PATIENTS/MATERIALS/METHODS: We conducted a retrospective single-centre study in consecutive patients consulting between 2010 and 2018 with an active BL-suspected non-immediate CADR and explored by cutaneous tests [patch tests (PT) and intradermal tests (P-IDR)] for at least three penicillin's subclasses and amino- and non-amino-cephalosporins (at least one aminocephalosporin). Cross-reactivity among subclasses was investigated for patients with positive tests. RESULTS: We included 56 patients, among whom 46 amoxicillin-suspected were and seven cephalosporin-suspected. Twenty-nine had severe CADR, and 27 had non-immediate maculopapular exanthema (MPE). Twenty-two had positive tests (18 for AS and four for CS). Among the 18 positive amoxicillin-suspected, 10 (55.6%) showed cross-reactivity with one or more other BL: 9 (50%) with another penicillin and 3 (16.5%) with a non-aminocephalosporin. No amoxicillin- or cephalosporin-suspected patient showed cross-reactivity with aztreonam or carbapenems. P-IDR showed cross-reactivity only once. CONCLUSION: After a suspected BL-induced non-immediate CADR, a large allergologic exploration is needed to confirm the diagnosis and evaluate cross-reactivity. In our population including cases of severe CADRs and MPE with late delay of onset, cross-reactivity was frequent and PT was sufficient to this purpose. The frequent cross-reactivity among penicillins encourages stopping this whole family and to test cephalosporins, aztreonam and carbapenems for which cross-allergies are rarer.

Variations in the recognition of echovirus type 11 strains by a group-specific anti-VP1 monoclonal antibody.

BACKGROUND: Mab 5-D8/1 is a monoclonal antibody (Mab) that was shown to be directed towards a conserved epitope of the capsid protein VP1 among the genus enterovirus. The use of this Mab for the routine detection of enteroviruses in clinical specimens led to the observation that several strains of echovirus type 11 (EV-11) could not be detected on spontaneously detached cells from 26-h cultures using a two-step immunofluorescence (IF) assay. Conversely, these strains were detected positive with the same Mab when tested on adherent or trypsinizated cells. OBJECTIVES: The aim of this study was to understand the misrecognition of some strains of EV-11 by this Mab. STUDY DESIGN AND RESULTS: IF tests at different times of the viral cycle brought evidence that the detection of a variant strain of EV-11 decreased rapidly with time, becoming undetectable 26 h post-infection, since the reference strain remained positive up to 46 h post-infection. The infective titres of the variant strains were shown to be high in comparison with those of well-recognised strains. Sequencing the Mab binding epitope confirmed that the variant strains exhibited no antigenic shift. CONCLUSION: These results suggest that the poor recognition of some strains of EV-11 by Mab 5-D8/1 is due to a rapid decrease of the expression of the binding epitope in the cell, maybe in relation with the high lytic power of these strains. From a practical point of view, our data indicate that a negative result when Mab 5-D8/1 is used for enterovirus typing must be interpreted cautiously with highly replicative strains and that detached cells should not be used for enterovirus identification under these circumstances.

Arbitrarily-primed PCR confirms the differentiation of strains of Ureaplasma urealyticum into two biovars.

Fourteen serotypes are currently recognized in the Ureaplasma urealyticum species. These serotypes have been divided into two genomic clusters or biovars by a large number of typing methods. The parvo-biovar includes strains of serotypes 1, 3, 6 and 14 and the T960-biovar, strains belonging to the ten other serotypes. In this study, arbitrarily primed polymerase chain reaction (AP-PCR) has been applied to the analysis of reference strains of the 14 U. urealyticum serotypes. By using two different sets of 10-mer oligonucleotide primers, the method allowed the clear differentiation between the two known biovars of the species. However, further differentiation within a same biovar was only achieved for a few standard strains of the T960-biovar analysed by using a pairwise combination of primers. The reproducibility of AP-PCR profiles was shown on strains tested after repeated subcultures and with different thermal cyclers. Additional experiments were performed on forty isolates of U. urealyticum recovered from subjects of various origins. They confirmed that AP-PCR was able to identify the strains at the biovar level. With reference to the other typing methods, AP-PCR is easy to perform and can be applied to large numbers of strains for epidemiological purposes.

Characterization of nosocomial strains of Enterobacter aerogenes by arbitrarily primed-PCR analysis and ribotyping.

OBJECTIVE: To study the spread of strains of Enterobacter aerogenes in our hospital in 1992 and 1993 by using two genotypic markers, and to evaluate these methods for the epidemiological investigation of this species. DESIGN: Ribotyping (using two endonucleases) and arbitrarily primed (AP)-PCR (using two different 10-mer primers) were applied to the epidemiological typing of clinical strains of E aerogenes isolated from hospitalized patients. SETTING AND PATIENTS: The intensive care unit (ICU; 5 patients, 13 isolates), nephrology units (3 patients, 5 isolates), and surgery units (2 patients, 2 isolates) of the university hospital of Saint-Etienne (France). RESULTS: Eight epidemiologically unrelated isolates, chosen as controls, exhibited distinct profiles, both by AP-PCR and ribotyping. Two clones of E aerogenes circulated in the ICU; both were isolated successively from samples of a single patient who stayed in the unit for almost 1 year. A third clone was recovered from patients of surgery units. A fourth clone was shown to have infected patients of nephrology units. CONCLUSIONS: Ribotyping and AP-PCR appear to be reliable methods for typing E aerogenes strains implicated in nosocomial infection. The spread of independent clones of E aerogenes in different units of our hospital in 1992 and 1993 was demonstrated by both methods. This study emphasizes the need to choose the endonucleases or primers with care to obtain high discriminatory results in genotypic investigations.

Differentiation of Pseudomonas aeruginosa strains by ribotyping: high discriminatory power by using a single restriction endonuclease.

The genotypic diversity of 40 presumably epidemiologically unrelated strains of Pseudomonas aeruginosa belonging to nine different O-serotypes was analysed according to ribosomal DNA fingerprints. Ribotyping was performed with a digoxigenin-labelled DNA probe and four restriction endonucleases. Characteristic banding patterns of three to 12 bands were obtained with the different endonucleases. Among the 40 strains, eight, nine, 10 and 29 different ribotypes were differentiated with EcoRI, the combination EcoRI+HindIII, BamHI and PvuII, respectively. Poor correlations were noted between the results of serotyping and those of ribotyping. With the latter method, indices of discrimination were calculated for each enzyme from the data of the 40 unrelated strains: the values ranged from 0.678 for EcoRI to 0.979 for PvuII. Epidemiologically related samples were also tested; this enabled assessment of whether the method was able to cluster strains from a common origin with each of the enzymes tested. Ribotyping with PvuII endonuclease is proposed for screening large numbers of P. aeruginosa strains in epidemiological studies. Additional enzymes could be used to further increase the discrimination between isolates found to be indistinguishable with PvuII enzyme.

Arbitrarily primed PCR, ribotyping, and plasmid pattern analysis applied to investigation of a nosocomial outbreak due to Enterobacter cloacae in a neonatal intensive care unit.

In December 1992, Enterobacter cloacae was isolated from the oropharynx and respiratory tract of six ventilated neonates hospitalized in the intensive care unit (ICU) of our hospital. To establish the spread of the outbreak, 41 strains of E. cloacae were analyzed for genotypic markers by three methods: plasmid profile analysis, ribotyping with EcoRI or PvuII endonuclease, and arbitrarily primed (AP) PCR. The tested strains included 12 isolates from the 6 epidemic cases, 4 isolates from the respiratory tract of 4 children hospitalized in other wards during the same period, 13 isolates from 12 children hospitalized in pediatric units before or after the outbreak, and 12 epidemiologically unrelated isolates. Ribotyping and AP PCR demonstrated that each of the last 12 strains exhibited distinct genomic patterns, as did each of the strains isolated from neonates hospitalized before or after the epidemic peak. Conversely, two clones of strains were found among the isolates recovered in December, with concordant results being obtained by the three typing methods: the first clone included seven strains from five ventilated children in the ICU and two children from another ward; another clone was shared by one neonate in the ICU and an infant from another ward. These results indicate that ribotyping and AP PCR-the latter applied, to our knowledge, for the first time to the genotypic analysis of E. cloacae--represent very discriminatory tools for the investigation of nosocomial outbreaks caused by this species.

Ventilator temperature sensors: an unusual source of Pseudomonas cepacia in nosocomial infection.

A prospective study was undertaken to determine the source of Pseudomonas cepacia colonization and infection that had affected ventilated patients in an Intensive Care Unit (ICU) for three years. Thirty-eight patients undergoing mechanical ventilation were enrolled during a six-week period. Samples were taken from patients, ventilator circuits and the environment for culture. P. cepacia was isolated from the condensate formed in the ventilator circuit and the source of the contamination was shown to be the temperature sensor. Ribotyping of the representative strains of P. cepacia performed with two endonucleases, EcoRI and PvuII, confirmed the homogeneity of the isolates from patients and ventilator circuits. A modification of the procedure for disinfection of the temperature sensors resulted in the eradication of P. cepacia from the ICU.

Characterization of unrelated strains of Staphylococcus schleiferi by using ribosomal DNA fingerprinting, DNA restriction patterns, and plasmid profiles.

The molecular characteristics of 31 unrelated strains of Staphylococcus schleiferi isolated from 13 hospitals between 1973 and 1991 were determined by ribosomal DNA fingerprinting by using a digoxigenin-labeled DNA probe, genomic DNA restriction patterns, and plasmid profiles. Only six strains harbored one or two plasmids. DNA restriction analysis, which was carried out with five endonucleases (EcoRI, HindIII, PstI, PvuII, and ClaI), did not allow us to discriminate between isolates. Ribotyping with HindIII, ClaI, or EcoRI enzymes generated six, seven, and nine distinct patterns, respectively. With the combination ClaI-EcoRI, 13 ribotypes were obtained among the 31 strains, suggesting a relative heterogeneity within the species. Moreover, all strains shared two or three common bands, according to the endonuclease used, which were relatively specific for S. schleiferi in comparison with the ribosomal banding patterns described for other coagulase-negative staphylococci. These results illustrate that ribotyping can be used for the epidemiological investigation of S. schleiferi isolates and possibly for taxonomic analysis in this species.

Prognostic value of serum immunoglobulin A antibodies to pol gene products during HIV-1 infection.

Serum specimens from 66 HIV-1-infected subjects were tested by ELISA for the presence of IgA antibodies to HIV-1: 44 samples were found positive and 37 were confirmed by immunoblot. In these subjects, the presence of anti-HIV IgA antibodies was studied in relation to the total count of circulating CD4+ lymphocytes and to the level of serum IgA. A significative correlation (P < 0.03) was found between the absence of IgA to the subunit p68 of the reverse transcriptase and a count of CD4+ cell < 400/mm3 or total IgA level over 4.25 g/l. The same pattern was observed for the IgA antibodies to the p52 subunit but the association was just not significant (P < 0.07). No significant decrease was noted for the IgA directed towards the other proteins of HIV-1, especially the products of the gag gene.

Genotypic homogeneity of nosocomial Pseudomonas aeruginosa O12 strains demonstrated by analysis of protein profiles, DNA fingerprints and rRNA gene restriction patterns.

The spread in Europe of a single multiresistant strain of Pseudomonas aeruginosa serotype O12 has been suggested. This bacterium was responsible for a nosocomial outbreak in our hospital in 1988-1989. Three different epidemiological methods were used to analyze 30 strains isolated during five consecutive years. Protein profile analysis and chromosomal DNA fingerprinting with four different enzymes revealed closely related patterns. rRNA gene restriction fragment length analysis performed with a digoxigenin-labelled probe showed identical hybridization patterns with four to six bands according to the endonuclease used. Combination of the three typing methods showed genotypic homogeneity of these Pseudomonas aeruginosa O12 strains, despite a relative increase in their antibiotic resistance.

[Enterovirus infections and systemic clinical manifestations with prolonged inflammatory syndrome: association with a persistence of specific IGM antibodies]. / Entérovirose et manifestations cliniques systémiques avec syndrome inflammatoire prolongé: association avec une persistance des anticorps IGM spécifiques.

We report 9 cases of enteroviral infection associated with systemic inflammatory disease (including 4 cases of vasculitis, 1 case of periarteritis nodosa, 1 case of Sharp's syndrome). We then reviewed 36 cases of enteroviral infection with persistent IgM antibodies diagnosed in the virology laboratory in a 6-year period: among them 11 cases were found to present with subacute or chronic inflammatory disease. We conclude that enteroviruses might be important triggers of systemic inflammatory disease.

Comparison of excretory/secretory and circulating antigens of Toxoplasma gondii by enzyme immunoassay and immunoblotting.

Toxoplasma gondii trophozoites (RH strain) were cultured in embryonic fibroblasts in order to study the kinetics of production of excretory/secretory antigens, and the results were compared to the production of circulating antigens in an in vivo mouse model. By capture-ELISA, excretory/secretory antigens were first detected on the fourth day of culture whereas circulating antigens were first detected 1 day after infection. Similar concentrations of antigens were detected in both models as evidenced by comparable absorbance values. By immunoblotting, the excretory/secretory antigens were also detected later compared to circulating antigens (day 4 vs day 1). Seven major polypeptides were detected in both antigen preparations, six of them having the same molecular mass (110, 75, 48, 30, 24 and 22 kDa).