[Measles in the Nantes Teaching Hospital during the 2008-2009 epidemic]. / Rougeole au CHU de Nantes au cours de l'épidémie 2008-2009.

OBJECTIVE: A recent measles epidemic in France incited us to report and describe measles cases requiring hospitalization, to raise the awareness of health professionals on under-diagnosis and frequent complications of this viral disease. DESIGN: We carried out a retrospective and epidemiologic study of measles cases recorded in the Nantes Teaching Hospital between August 2008 and September 2009. All these cases where confirmed by biological diagnosis and recorded by the Teaching Hospital virological laboratory. RESULTS: Thirteen cases of measles (11 adults and two children) were recorded during the study period. Adults were young (mean age 21.4 years); the oldest was 35 years old. We noted two severe cases with viral pneumonia and hypoxemia and one case with bacterial pneumonia. Two female patients were pregnant; one delivered prematurely, in the acute phase of measles, with no complication for the newborn. Two cases occurred in the nursing staff by documented nosocomial transmission. Sixty-nine percent of the patients were not vaccinated whereas the vaccinal status was not documented for 31%. CONCLUSIONS: These cases underline the potential severity of this infection and the difficulty to diagnose measles at the early phase because of lack of awareness of medical staff. It will be necessary to reinforce prevention messages and promote measles vaccination in children as well as in young people and health workers.

[Epidemiological estimation of the effectiveness of the pertussis vaccination during outbreaks in a community. Les pédiatres et bactériologistes du réseau RENACOQ]. / Estimation épidémiologique de l'efficacité de la vaccination anticoquelucheuse au cours d'épidémies en collectivité. Les pédiatres et bactériologistes du réseau RENACOQ.

BACKGROUND: With the recent pertussis vaccine trials, the efficacy of acellular vaccines is now well known, estimated at 85% for multicomponent vaccines. On the other hand, the estimates of whole cell vaccines efficacy varies from 36% to 98% with the different vaccines used. We evaluated the field effectiveness of the French whole cell pertussis vaccine during outbreaks in schools and centers for disabled children. METHODS: Four limited outbreaks between 1993 and 1995 were investigated using a retrospective cohort study design. Vaccine effectiveness (VE) was assessed for the following case definition: clinical pertussis, laboratory-confirmed pertussis, epidemiologically confirmed pertussis (documented contact with a laboratory confirmed case). Immunization history was obtained by reviewing the child health record book. Effectiveness of a whole vaccination (four injections) and of a partial vaccination (one to three injections) were estimated as 1-(attack rate among vaccinated/attack rate among non-vaccinated). RESULTS: A whole immunization conferred good protection against pertussis with an estimated VE higher than 92% in three surveys, lower in the fourth survey (84%) in which antibiotic prophylaxis was set up very rapidly. A partial immunization conferred a mild protection (median: 60%). CONCLUSIONS: These results are consistent with a previous report about the effectiveness of this whole cell vaccine using the screening method in a hospital network survey in France. In the same way, a large efficacy trial in Senegal comparing it with an acellular bivalent vaccine estimated its efficacy at 96%. This high efficacy together with a satisfactory vaccine coverage leads to the current epidemiological profile of pertussis in childhood in France: majority of cases occurring before 6 months of age, limited outbreaks in school children, many of whom being unvaccinated or partially vaccinated.

Development of RT-semi-nested PCR for detection of hepatitis A virus in stool in epidemic conditions.

The purpose of this study was to determine the efficiency of semi-nested PCR in detecting hepatitis A virus (HAV) RNA. During a 2-year period (1990-1991), HAV RNA was searched for in shellfish from the French Brittany coasts using cRNA and vRNA probes. In January 1992, at the time of a hepatitis A outbreak, 28 stool samples were collected from infected patients (18 adults, 10 children) with anti-HAV IgM. Four samples from subjects with negative HAV serology were used as negative controls. Nucleic acid amplification (reverse-transcription-semi-nested PCR) was performed to detect HAV in stool. HAV RNA was purified by phenol-chloroform extraction and converted to cDNA using reverse transcriptase (Mu-MLV). After amplification, PCR products were visualized on an ethidium-bromide-stained gel and confirmed by hybridization with a specific digoxigenin-labelled oligoprobe. Samples were also studied by molecular hybridization with cRNA and vRNA probes. After onset of the illness, HAV RNA was detected over a longer time period by semi-nested PCR (16/28) than by hybridization (0/28). Even though biological diagnosis of hepatitis A will continue to rely on the detection of anti-HAV IgM, PCR should be useful in certain clinical cases (diagnosis of relapse) and for epidemiological and environmental monitoring of viruses.

[Limitations of normal eosinophilia or possible influence of nonsteroidal anti-inflammatory agents]. / Les limites de l'éosinophilie "normale" ou l'influence possible des anti-inflammatoires non stéroïdiens.

Statistical analysis of eosinophilia of 331 patients at the onset of hospitalisation define a logarithmic standard population of 327 patients whose eosinophilia rates stand between 0 and 810/mm3, among them 24 lies between 500 and 810, and 4 whose eosinophilia rise over 1,000/mm3. These 4 patients had transient hypereosinophilia whose etiology was defined only in 2 cases. The 24 patients with eosinophilia between 500 and 810/mm3 were significantly more frequently men, with rheumatoid disease (specially sciatica) and users of non steroidal antiinflammatory drugs (NSAID) than the general population. It suggest that NSAID may rise eosinophilia rates inside normal limits.

[Evaluation of drug consumption by hospitalized patients. Prospective survey]. / Evaluation de la consommation médicamenteuse des sujets hospitalisés. Enquête prospective.

Drug use was assessed in a prospective 6-month study carried out in the Department of General Medicine V and Rheumatology of the Nantes Regional Hospital Center. An attempt was made to evaluate consumption as realistically as possible, and a judgment was made based on the consensus of the medical team as to whether the prescription was justified or not. The mean number of drugs consumed by each patient was 2.8; 60% being prescribed for cardiovascular and neuropsychiatric purposes. As 33% of the prescriptions were considered unnecessary, it would appear that use was excessive in these hospitalized patients.

[Iatrogenic disease. Prospective study, relation to drug consumption]. / Pathologie iatrogène. Enquête prospective, lien avec la consommation médicamenteuse.

The role of drug use in iatrogenic pathology was studied prospectively in a hospital department. It wa s found that patients received an average of 2.8 drugs and that 30% of the prescriptions were unnecessary. During this six-month study of all patients admitted to a general medicine and rheumatology department, there were 67 iatrogenic accidents affecting 12.3% of the population: 41.8% of the accidents were directly responsible for hospitalization, 35.4% were due to therapy initiated during hospitalization and 32.8% occurred during the hospital stay but were the result of earlier treatment. Moreover, 26% of the accidents were related to what was considered to be unnecessary therapeutics. This study shows that elevated iatrogenic pathology was due to excessive drug use. However, the degree of severity of the adverse effects varied considerably, and some could have been easily avoided.

The efficacy of selective unilateral temporal artery biopsy versus bilateral biopsies for diagnosis of giant cell arteritis.

Two hundred bilateral temporal artery biopsies performed prospectively in 200 patients suspected of having giant cell arteritis (GCA) were always preceded by Doppler flow study and local clinical examination. If bilateral temporal artery biopsies had been guided by positive local clinical examination, 24 positive biopsies would have been found, and Doppler studies would have improved the diagnostic score to 39; however, the biopsies gave 42 histologically positive results, providing the best diagnostic yield. The possibility of GCA with normal Doppler flow studies was noted as well as the existence of relatively asymptomatic forms of GCA, so that systematic performance of bilateral temporal artery biopsy would seem justified in any case of suspected GCA.

Chronic myelomonocytic leukemia and primary Sjögren's syndrome.

Although associations of Sjögren's syndrome (SS) with malignant affections are well known, an association with chronic myelomonocytic leukemia (CMML) is infrequent. Our report concerns an 80-year-old woman with chronic polyarthrosis, hospitalized for an anemic syndrome, who also complained of buccal dryness. Clinical examination showed simply parotid swelling and discrete splenomegaly. The diagnosis of SS appeared to be primary. The hemogram, myelogram and bone biopsy indicated CMML. During SS, the possibility of occurrence of a lymphoproliferative syndrome is well documented, and other malignant affections are much less likely to be found in the absence of immunosuppressive treatment. The particular case of SS and associated CMML detected at the same time suggests either the favorable role of monocytic proliferation on immunity or a stem clonal anomaly affecting monocytes and B lymphocytes.

[Paraneoplastic dermatopolymyositis]. / Dermatopolymyosites paranéoplasiques.

In a retrospective study covering 11 years, 59 adult cases of dermatomyositis or polymyositis were reviewed. The disease was of paraneoplastic origin in 9 cases (15,25 p. 100), the same proportion as that found in the literature (14,6 p.100). The striking female predominance (8/9 cases) and the patients' mean age (61.11 years) were higher than those noted in non-paraneoplastic dermato- and polymyositis in adults (female predominance 34/50, mean age 52.9 years). Clinically, out of 9 patients 7 had dermatomyositis and 2 had polymyositis. The disease was discovered at the same time as the neoplasia in 7 of the 9 cases. Muscle histology showed that in contrast with non-paraneoplastic cases of dermatomyositis-polymyositis those of paraneoplastic origin had moderate lesions without fibrosis.

[Primary Gougerot-Sjögren syndrome with necrotizing polymyositis: favorable effect of hydroxychloroquine]. / Syndrome de Gougerot-Sjögren primitif avec polymyosite necrosante: effet favorable de l'hydroxychloroquine.

A 61-year-old woman was admitted for acute arthralgias and proximal weakness in all four limbs. Clinical examination found xerostomia, xerophthalmia, enlarged parotid glands. The Schirmer test was positive and the salivary gland biopsy showed a mononuclear, lymphoid, sometimes nodular infiltrate. A muscle biopsy showed necrotizing myopathy with perifascicular atrophy. The patient refused steroids and was given hydroxychloroquine (600 mg daily). She improved gradually, and one year later there were no further complications. The favorable course both of Sjögren's syndrome and polymyositis with hydroxychloroquine treatment is unexpected. This led us to suppose that both could have had a common cause.

[Clavicle osteolysis in MacDuffie's syndrome]. / Ostéolyse claviculaire au cours d'un syndrome de MacDuffie.

MacDuffie's syndrome emerges from systemic vasculitis as including recurrent urticaria-like skin lesions, episodic angio-oedemas, articular manifestations and abdominal pains, with a tendency to affect women. Renal involvement may burden the prognosis. Hypocomplementemia is usual by deficiency of the classical pathway. Corticosteroid therapy is habitual. The case reported, fitting to this nosological entity offers two new features: in the first place, the osteolysis of the distal part of the clavicle whereas the joints are not affected by destroying lesions; then the non steroidal anti-inflammatory drugs was effective within a period of one year without complication.

[Clinical and etiological aspects of erythema multiforme. A propos of 40 cases]. / Aspects clinique et étiologique de l'érythème polymorphe. A propos de quarante observations.

The authors analyse 40 cases of erythema multiforme (including twenty children under fifteen) seen over a five-year period at the Sick Children's Hospital in Bordeaux, Bullous erythematous target lesions of the skin were associated, in most cases, with pluri-orificial ulcerations on the mucous membranes and, less frequently, with more or less severe systemic or visceral symptoms. Borderline cases were observed, associating features of erythema multiforme simplex and of Lyell disease with variable degrees of dermoepidermal blistering and epidermal necrosis. Infection (32.5% of cases) is a more common etiology in children than in adults; the main pathogens are herpes simplex virus, vaccinia pox virus, and Mycoplasma pneumoniae. Drug-induced forms (37% of cases), which are more often seen in adults than in children, are usually due to sulfonamides or antiinflammatory agents. In 30% of cases, no etiology could be demonstrated. Attention is drawn to the frequency of facial vespertilial erythema, as well as the possible occurrence of severe conjunctival sequellae. The connections between erythema multiforme, fixed drug-induced eruptions, and Lyell disease are discussed: only the last, which implies dermoepidermal cleavage, can be categorized with erythema multiforme. The staphylococcal scalded skin syndrome, in which the epidermolysin of Staphylococcus aureus type II 71 is responsible for a superficial cleavage, proceeds from entirely different mechanisms and should be regarded as totally distinct from erythema multiforme.