A Mailles

European Bat Lyssavirus Transmission among Cats, Europe

We identified 2 cases of European bat lyssavirus subtype 1 transmission to domestic carnivores (cats) in France. Bat-to-cat transmission is suspected. Low amounts of virus antigen in cat brain made diagnosis difficult.

Real-Time PCR for Diagnosis of Oculoglandular Tularemia

To the Editor: Oculoglandular tularemia accounts for 3%–5% of all diagnosed tularemia cases (1). We report the diagnosis of this disease in 2 patients in France by real-time PCR. Patient A, a 43-year-old woman, was referred in October 2006 to the infectious disease department of Auch Hospital (Auch, France). She had a fever (39°C) and severe conjunctivitis of the right eye that had evolved over 2 weeks despite administration of amoxicillin/clavulanate. The patient lived in a rural area endemic for tularemia and had regular contact with dogs and ring doves. She remembered harvesting mushrooms in a nearby forest a few days before onset of clinical symptoms. Physical examination showed a hyperemic and painful right conjunctiva, enlarged (0.5–1.5 cm in diameter) and tender preauricular and submandibular lymph nodes, and cellulitis of the right hemiface. Her condition rapidly improved after she received doxycycline and gentamicin. Patient B, a 42-year-old woman, was referred in October 2008 to the infectious disease department of Dijon University Hospital (Dijon, France) for intermittent fever (38.5°C) and swollen left-sided pretragal and cervical lymph nodes, which had evolved for 3 weeks despite administration of amoxicillin, followed by pristinamycin and prednisone, and ciprofloxacin for 7 days. The patient remembered being scratched on the left hand by her dog several weeks earlier; the scratch healed spontaneously. She had recently walked in a nearby forest that was endemic for tularemia. Physical examination showed enlarged (2–3 cm in diameter), tender lymph nodes and bilateral conjunctivitis. Her condition improved after doxycycline therapy, but the pretragal lymph nodes were removed surgically in late November 2008 because of suppuration and necrosis. Ofloxacin was administered until January 2009 because of persistence of inflammation in cervical lymph nodes and suppuration with skin fistulization in the pretragal region. Diagnostic investigations (Table) conducted at Grenoble University Hospital included serologic tests (microagglutination and indirect immunofluorescent antibody assay by using locally prepared Francisella tularensis subsp. holarctica antigen), culture, and 2 real-time PCRs. These PCRs were specific for insertion sequence ISFtu2 or the Tul4 protein–encoding gene of Francisella sp. and used previously described primers, probes, an amplification protocol (2), and a LightCycler 2.0 apparatus (Roche, Meylan, France). We tested 5 μL of DNA extracted from clinical samples by using the QIAamp DNA Mini kit (QIAGEN, Hilden, Germany). Three negative controls (DNA-free water) and 1 positive control (DNA extracted from the F. tularensis subsp. holarctica LVS strain) were used for each PCR. Table Characteristics of the 2 patients in the study and test results for tularemia, France* Seroconversion was found between acute-phase and convalescent-phase serum samples from both patients. A conjunctival cotton swab sample from patient A and pretragal lymph node suppuration and biopsy samples from patient B were positive for F. tularensis by both real-time PCRs. A Francisella sp. strain was isolated from the conjunctival discharge from patient A at Auch Hospital and Grenoble Hospital laboratories. Cultures were grown in a BioSafety Level 3 laboratory at Grenoble University Hospital because results of both PCRs were positive. Cultures of specimens from patient B were negative. Both patients were infected with an F. tularensis subsp. holarctica strain. Infection was identified by PCR amplification and sequencing of the 16S rRNA gene (fD1 and rP2 primers) and the intergenic spacer region (FTitsFw 5′-ACCACGGAGTGATTCATGACTG-3′ and FTitsRv 5′-TCTCAATTGATTTCTCTTCCTAAGG-3′ primers) from the strain isolated from patient A and directly from the lymph node biopsy specimen from patient B. Conjunctival inoculation of F. tularensis usually occurs by contact when a contaminated finger comes into contact with the eyes, e.g., after handling of an infected animal or tick (3,4), but the source of infection often remains undetermined, as for our 2 patients. Symptoms are not specific and correspond to Parinaud oculoglandular syndrome (1). Reported complications include keratitis, occasional corneal perforation, and lymph node suppuration; tonsillitis, cellulitis in nearby skin tissue, retinitis, erythema nodosum, and progression to systemic disease occur less frequently (3–7). A specific microbiologic diagnosis is needed for appropriate treatment because many microorganisms can cause Parinaud oculoglandular syndrome and clinical symptoms are not specific (1,8). Fluoroquinolones are now considered first-line treatment for tularemia; β-lactam antimicrobial agents are not effective (9). Oculoglandular tularemia is a painful disease with a short incubation period (3–5 days), and results of serologic tests of acute-phase samples are often negative (1,9). Isolation of F. tularensis is difficult and hazardous to laboratory personnel (1,9). PCR-based techniques may enable a more rapid diagnosis (1,9,10). Heating clinical samples before testing prevents laboratory-acquired infections. We report the use of real-time PCR for detection of F. tularensis from a conjunctival swab specimen. Many clinical laboratories are now equipped with this technology. Transport conditions of clinical samples (4°C, no transport medium, 24–48 h) are not restrictive. When compared with PCR, real-time PCR does not require post-PCR processing, enabling a faster turn-around time. Oculoglandular tularemia is a rare but underestimated disease. Real-time PCR detection of F. tularensis DNA from conjunctival swab suspensions now provides a rapid, noninvasive, sensitive, and specific diagnosis of oculoglandular tularemia. This assay enables early establishment of specific antimicrobial drug therapy and poses no risk of infection for laboratory staff.

Travel-associated and autochthonous Zika virus infection in mainland France, 1 January to 15 July 2016

During summer 2016, all the conditions for local mosquito-borne transmission of Zika virus (ZIKV) are met in mainland France: a competent vector, Aedes albopictus, a large number of travellers returning from ZIKV-affected areas, and an immunologically naive population. From 1 January to 15 July 2016, 625 persons with evidence of recent ZIKV infection were reported in mainland France. We describe the surveillance system in place and control measures implemented to reduce the risk of infection.

Brucella suis biovar 2 infection in humans in France: emerging infection or better recognition?

Brucellosis is usually acquired by humans through contact with infected animals or the consumption of raw milk from infected ruminants. Brucella suis biovar 2 (BSB2) is mainly encountered in hares and wild boars (Sus scrofa), and is known to have very low pathogenicity to humans with only two case reports published in the literature. Human cases of brucellosis caused by BSB2 were identified through the national mandatory notification of brucellosis. The identification of the bacterium species and biovar were confirmed by the national reference laboratory. Epidemiological data were obtained during medical follow-up visits. Seven human cases were identified between 2004 and 2016, all confirmed by the isolation of BSB2 in clinical specimens. All patients had direct contact with wild boars while hunting or preparing wild boar meat for consumption. Five patients had chronic medical conditions possibly responsible for an increased risk of infection. Our findings suggest that BSB2 might be an emerging pathogen in hunters with massive exposure through the dressing of wild boar carcasses. Hunters, especially those with chronic medical conditions, should be informed about the risk of BSB2 infection and should receive information on protective measures.

Strengthened Ebola surveillance in France during a major outbreak in West Africa: March 2014–January 2016

Introduction An unprecedented outbreak of Ebola virus diseases (EVD) occurred in West Africa from March 2014 to January 2016. The French Institute for Public Health implemented strengthened surveillance to early identify any imported case and avoid secondary cases. METHODS Febrile travellers returning from an affected country had to report to the national emergency healthcare hotline. Patients reporting at-risk exposures and fever during the 21st following day from the last at-risk exposure were defined as possible cases, hospitalised in isolation and tested by real-time polymerase chain reaction. Asymptomatic travellers reporting at-risk exposures were considered as contact and included in a follow-up protocol until the 21st day after the last at-risk exposure. RESULTS From March 2014 to January 2016, 1087 patients were notified: 1053 were immediately excluded because they did not match the notification criteria or did not have at-risk exposures; 34 possible cases were tested and excluded following a reliable negative result. Two confirmed cases diagnosed in West Africa were evacuated to France under stringent isolation conditions. Patients returning from Guinea (n = 531; 49%) and Mali (n = 113; 10%) accounted for the highest number of notifications. CONCLUSION No imported case of EVD was detected in France. We are confident that our surveillance system was able to classify patients properly during the outbreak period.